Transcript Risperidone (Risperdal)

Practical Prescribing for
Vulnerable Community Living
Elderly
University of Cincinnati / Health Alliance
Reynolds Geriatric Education Center
Presentation Outline
 Review the challenges of prescribing
for the Vulnerable seniors ;
 Examine risks factors for Adverse
Drug Events;
 Propose strategies to improve
prescribing outcomes;
 Suggest resources available for
continual support in managing
medications in seniors.
6
Prescribing Challenges

Effective drug treatments for chronic illnesses
have expanded, and many older people have
multiple chronic illnesses

Adverse drug reactions (ADEs) and drugdrug/drug-disease interactions increase as the
number of prescribed medications increases

Adherence to complex, multiple drug regimens is
difficult: poor vision, poor memory, limited funds,
etc.
7
Gaps in Our Understanding of Medication
Use in the Elderly

Safety and effectiveness of any given
medication is not well studied in the aged

Multiple concomitant medications
adversely effect the safety and
effectiveness of individual medications

Multiple medical problems can adversely
effect the outcomes of pharmacotherapy
8
Adverse Drug Events (ADEs)
 Use of multiple medications is the primary
risk factor for experiencing an ADE
 Multiple chronic medical conditions
increases the risk for ADEs
 Many ADEs are predictable and therefore
preventable
9
Risk Factors for Adverse Drug Events
in Older Patients








> 6 concurrent chronic diagnoses
>12 doses of medications/day
> 9 medications
Multiple Prescribing Physicians
A prior ADE
Low body weight
Age >85 years
Creatinine clearance <50 ml/minute
10
Adverse Drug Effect Cascade
11
15
Mrs. Janet Andrews
An 86 year old patient comes to your
office with her daughter. She last saw
you more than a month ago when you
completed a preoperative exam prior to
an elective hip replacement.
Mrs. Andrews was in the hospital for
one week and in a nursing home for 3
weeks and is now back in her own home.
12
Pre-operative MedsMost concern?
1.
Digoxin
2.
Enalapril (Vasotec)
3.
Warfarin
4.
Tylenol PM
5.
Dicyclomine (Bentyl)
6.
More than one of the above
13
Post-operative Symptom: Confusion
Least likely contributor?
1.
Digoxin
2.
Tylenol PM
3.
Amiodarone (Cordarone)
4.
Oxycodone
5.
Warfarin
14
Post-operative Symptom: Poor Appetite
Least likely contributor?
1.
Digoxin
2.
Enalapril (Vasotec)
3.
Valdecoxib (Bextra)
4.
Amiodarone (Cordarone)
5.
Oxycodone
15
Post-operative Symptom: Constipation
Least likely contributor?
1.
Digoxin
2.
Tylenol PM
3.
Amiodarone (Cordarone)
4.
Oxycodone
5.
Warfarin
16
Post-operative Sign: Bradycardia
Least likely contributor?
1.
Digoxin
2.
Enalapril (Vasotec)
3.
Amiodarone (Cordarone)
4.
Dicyclomine (Bentyl)
17
Today, would you discontinue or decrease
the dose of one of these medications?
1. Digoxin
2. Enalapril (Vasotec)
3. Valdecoxib (Bextra)
4. Amiodarone (Cordarone)
5. None of the above
18
During future visits, would you discontinue or
decrease the dose of one or more of these
medications?
1. Dicyclomine
2. Ferrous sulfate
3. Oxycodone
4. Tylenol PM
5. Two of the above
6. Three of the above
7. All of the above
19
Benefit vs Risk
 Appropriate medication use requires
that benefits of therapy clearly
outweigh the associated risks.
 Benefit-to-risk ratio is unique to an
individual; the very medication and
dosage that helps one patient may
harm another.
20
Prescribing Suggestions with
Vulnerable Seniors: Basic Strategies
Prescribing ALL, indicated medications,
may NOT be the best approach
2. Triage medications:
1.
 Start with most needed first, assess impact;
then add second most important, etc.
3.
Some conditions assumed to be “aging”
can be ADEs – e.g., confusion, falls,
incontinence
21
Helping Your Patients (I)
 Encourage Use of Patient Medication
Logs
 Assess ability to take correctly
 Take advantage of Medication
Adherence Aids
 Keep Costs Down
22
Helping Your Patients (II)
 Use One Drug to Treat Multiple
Problems (For example, use
antidepressant side effects)
 Avoid High Risk Medications
 Drug-Drug Interactions
 Drug-Disease Interactions
23
Where to get help



UC/Health Alliance Reynolds Grant ‘Email
Geriatrics Consultation’: [email protected]
Net Wellness at http://www.netwellness.org
American Geriatrics Society at
http://www.americangeriatrics.org
 Medicaid Drug Benefit (AGS) at
http://www.americangeriatrics.org/policy/medicare
_info.shtml
24
Where to get help



National Guideline Clearing House at
http://www.guideline.gov
Medscape at http://www.medscape.com
Assistance Programs for Low Income
older adults from Drug Manufacturers
http://needymeds.com/
25
Patient Medication Log
 Prescription drugs - from all providers
 Trans-dermal medications
 Inhalers
 OTC drugs
 Vitamins and Dietary Supplements
 Eye & ear drops
 Topical agents
26
Medication Adherence Aids
1. Prefer QD or BID regimens
2. Pill boxes to organize and provide
reminders
27
Example 4 x 7 compliance Aid
28
Example 1x7 Compliance Aid
29
Using One Drug to Treat Multiple Problems
76 y.o. patient with depressive symptoms,
weight loss, and insomnia.
 One drug could in theory treat all of
these medical problems…
Variation on this theme:
Choose by the side effect you want or least
desire when selecting otherwise
“therapeutic equivalent” medications
30
Avoid Drug-Drug Interactions that
are Associated with Hospitalization
ACE-inhibitor plus…
 Potassium sparing diuretic or potassium
 Benzodiazepine plus…
 Antidepressant, antipsychotic, or another
benzodiazepine
 Warfarin and new antibiotic prescription
 Diuretic plus…..
 Digoxin, nitrate, or another diuretic

31
Avoid Drug-Disease Interactions
 NSAIDs and History of Upper GI
bleeding
 Anticholinergics medications:
 BPH/Bladder outlet obstruction
 Alzheimer’s Disease
 Chronic Constipation
 Benzodiazepines/Tricyclic
antidepressants and Falling/Gait
Disturbances
32
Help Patients Keep Costs Down (I)

Prescribe a less expensive comparable
brand or generic drug in the same drug
class.
 Optimize dosing. (Does taking the total
amount of the drug once daily save money
and is it still effective?)
 Determine if cutting pills in half will reduce
costs
33
Help Patients Keep Costs Down (II)

Suggest using Mail Order for chronic
medications.
 Use Assistance Programs for Low
Income Seniors from Pharmaceutical
Manufacturers
http://needymeds.com/
34
Prescribing for Vulnerable Seniors
Clinical Topics
 Anti-cholinergic Medications
 Analgesics
 Sedative-Hypnotics
 Oral Agents for Type II Diabetes
 Dietary Supplements
35
Avoid Medications with High
Anti-Cholinergic Properties (I)
 Antihistamines in general and
diphenhydramine (Benadryl) in
particular
 Omnipresent in OTC sedatives,
cough and cold, sinusitis etc.
 For antihistamines use loratadine
(Claritin) or fexofenadine (Allegra)
36
Avoid Medications with High
Anti-Cholinergic Properties (II)
 Tricyclic Antidepressants,
 Anti-spasmotics,
 Anti-psychotics,
 Anti-parkinsonian and muscle
relaxants,
 Incontinence medications
37
Analgesics-Choose Carefully (I)
Acetaminophen – 1st Choice for Chronic
Pain
 NSAIDS - COX-2 or Non-selective –Use
cautiously ONLY for short term treatment,
avoid for chronic pain or add PPI
 Tramadol (Ultram) – Possible 2nd Choice for
chronic pain

38
Analgesics-Choose Carefully (II)

Use scheduled narcotics to reduce
chronic pain
 Avoid: Propoxyphene, meperidine,
trans-dermal agents
AGS Chronic Pain Guidelines at
http://www.americangeriatrics.org/education/manage_pers_p
ain.shtml
Partners Against Pain at
http://www.partnersagainstpain.com/index-mp.aspx?sid=3
39
Sedative/hypnotics (I)
 Trazodone
 GABA selective agents – zolpidem
(Ambien) or zaleplon (Sonata)
40
Sedative/hypnotics (II)

Non-GABA selective benzodiazepine




Lorazepam
Oxazepam
Temazepam
Choose a moderate half-life agent if need
regularly
 All can cause falls, memory impairment,
“retrograde” amnesia, tolerance and withdrawal
41
Oral Agents for Diabetes (I)

How tight to control frail elderly?
 If insulin used, do you need oral agent?
 Insulin sensitizers – Actos, Avandia-use
cautiously
 May increase CHF symptoms,
peripheral edema
42
Oral Agents for Diabetes (II)

Hypoglycemia more likely to occur with
metformin and/or beta-blockers
 Lactic acidosis more likely with
metformin when used in seniors with
renal impairment
 Consult Am Assoc Clinical
Endocrinologists at
http://www.aace.com/clin/guidelines/
43
Dietary Supplements (I)
 St. John’s Wort can increase drug
metabolism (P450/CYP3A4)
 “G-Team” all have antiplatelet effects
 Ginkgo Biloba; Garlic; Ginger
 Saw Palmetto – no reported drug
interactions
 Kava Kava – associated with
hepatoxicity
44
Dietary Supplements (II)
 Echinacea – avoid long term use;
agent decreases immune response
 Resources:
 Natural Medicine Database http://www.naturaldatabase.com/
 The Prescriber’s Letter at
http://www.prescribersletter.com
45
Practical Prescribing for Vulnerable
Community Living Older Adults
Part Two
Managing Common Clinical Problems
46
Mrs. Janet Andrews
Mrs. Andrews returns for f/u one month after her
last visit. A number of her medications have
been discontinued or dosing was reduced. In
general she is doing better. Less confused, no
constipation, improving hydration and anemia.
She continues to have trouble walking and
sleeping. Although her appetite is better she
has lost another 2 lbs to 108 lbs (10 lbs in the
last 2 months). She has added several dietary
supplements to improve her medical problems.
New symptoms are increasing anxiety and
agitation, and easy bruising.
47
Continuing Weight Loss / Poor Appetite:
LEAST Likely Contributor
1. Digoxin
2. Ferrous sulfate
3. St John’s Wort
4. Kava kava
5. Anxiety / agitation
6. Depressive symptoms
48
Minor depression with anxiety and insomnia:
BEST treatment choice?
1. St Johns Wort
2. Fluoxetine extended release
(Prozac weekly)
3. Escitalopram (Lexapro)
4. Mirtazapine (Remeron)
5. Trazodone (Desyrel)
49
Potentiating Warfarin / Easy Bruising:
LEAST Likely
1. Tylenol
2. Gingko Biloba
3. Garlic
4. Glucosamine/chondrotin
5. Limited dietary vitamin K
50
Dietary Supplements (I)
 St. John’s Wort can increase drug
metabolism (P450/CYP3A4)
 “G-Team” all have antiplatelet effects
 Ginkgo Biloba; Garlic; Ginger
 Saw Palmetto – no reported drug
interactions
 Kava Kava – associated with
hepatoxicity
51
Dietary Supplements (II)
 Resources:
 Natural Medicine Database http://www.naturaldatabase.com/
 Herb Med at
http://www.herbmed.org/about.asp
 The Prescriber’s Letter at
http://www.prescribersletter.com
52
Insomnia: Which medication would be
best to recommend?*
1. Trazodone 50 mg po qHS
2. Zolpidem (Ambien) 10 mg take ½ tablet
(5 mg) po qHS PRN
3. Temazepam 15 mg capsule po PRN
4. Mirtazepine (Remeron) one-half of 30 mg
tablet (15 mg) qHS
5. Zalepion (Sonata) 5 mg po qHS prn early
awakening
* Along with counseling on good sleep hygiene (avoid naps, improve sleep
environment schedule daytime activity etc)
53
Persistent Pain: 5 on scale of 10
MODIFY or ADD
1. Propoxyphene/acetaminophen (Darvocet)*
2. Hydrocodone/acetaminophen (Vicodin)*
3. Naproxen (Naprosyn)
4. Celecoxib (Celebrex)
5. Fentanyl patch (Duragesic)
*These choices require discontinuation of acetominophen
1 gram four times a day.
54
Analgesics-Choose Carefully
 Use scheduled narcotics to reduce
chronic pain
 Avoid: Propoxyphene, meperidine,
trans-dermal agents
AGS Chronic Pain Guidelines at
http://www.americangeriatrics.org/education/manage_pers_pain.shtml
Partners Against Pain at
http://www.partnersagainstpain.com/index-mp.aspx?sid=3
55
Mr. Robert Jacobs
An 82 year old patient comes to your office
with his wife for a follow-up visit. He is
returning from a 2-month stay in Florida and
has not seen you for three months. While he
was in Florida, Mr. Jacobs was evaluated in
the emergency room for an episode of
dizziness and delirium. He was treated for a
UTI and several medications were adjusted.
Today, Mr. Jacobs remains dizzy, is unsteady
when he walks, is still confused, is sleepy, has
urinary frequency, knee pain, and a poor
appetite.
56
Dizziness and Unsteadiness:
Least Likely Contributor
1.
Terazosin (Hytrin)
2.
HCTZ
3.
Lisinopril
4.
Rosiglitazone (Avandia)
5.
Risperidone (Risperdal)
57
Confusion and Sleepiness:
Most Likely Contributor
1.
Celecoxib (Celebrex)
2.
Donepezil (Aricept)
3.
Risperidone (Risperdal)
4.
Lisinopril
5.
Glipizide
58
Poor Appetite:
Least Likely Contributor
1.
Donepezil (Aricept)
2.
Terazosin (Hytrin)
3.
Celecoxib (Celebrex)
4.
Risperidone (Risperdal)
5.
Tolterodine (Detrol)
59
Urinary Frequency:
Most Likely Contributor
1.
Terazosin (Hytrin)
2.
Celecoxib (Celebrex)
3.
Tolterodine (Detrol)
4.
Glipizide
5.
Risperidone (Risperdal)
60
Today, would you discontinue or decrease
the dose of one of these medications?
1.
Decrease Aricept dose
2.
Decrease Hytrin dose
3.
Discontinue Celebrex
4.
Discontinue Detrol
5.
Decrease Lisinopril dose
61
During future visits, would you discontinue or
decrease the dose of one or more of these
medications?
1.
Terazosin (Hytrin)
2.
Tolterodine (Detrol)
3.
Celecoxib (Celebrex)
4.
Risperidone (Risperdal)
5.
Two of the above
6.
Three of the above
7.
All of the above
62
Oral Agents for Diabetes (I)

How tight to control frail older adult?
 If insulin used, do you need oral agent?
 Insulin sensitizers – Actos, Avandia-use
cautiously
 May increase CHF symptoms,
peripheral edema
63
Oral Agents for Diabetes (II)

Hypoglycemia more likely to occur with
metformin and/or beta-blockers
 Lactic acidosis more likely with
metformin when used in older adults
with renal impairment
 Consult Am Assoc Clinical
Endocrinologists at
http://www.aace.com/clin/guidelines/
64