Polypharmacy

The Brown Bag A 92 year old man comes to your office to establish a primary care relationship after having just been discharged from another hospital. He was admitted for a GI bleed but his stay was complicated by delirium, acute vision loss in his left eye, a large occipital lobe stroke, and the discovery of severe aortic stenosis and coronary artery disease. Since his discharge, he has required an in-home caregiver and reports much functional loss, as well as concerns about his balance and cognitive abilities. As requested, he brings all of his medications with him for evaluation.

The Brown Bag The bag contains the following: 1. Omega 3 fatty acid capsules 2. Vitamin E 3. Stelazine 2 mg @ hs 4. Percocet q4 hr 5. Propanolol 10 mg qd 6. Aspirin 81 mg qd 7. Vitamin B complex 8. Lipitor 10 mg qd 9. Metoprolol 50 mg bid 10. Prilosec 20 mg qd 11. Imipramine 25 mg qhs 12. Fish oil capsules 13. Propoxyphene/acetaminophen q6 hr prn 14. Flurazepam 15 mg qhs 15. Ranitidine 150 mg bid 16. Tylenol PM, over the counter prn 17. Digoxin 0.25 mg qd

The Brown Bag What are his risk factors for polypharmacy? List as many concerns about this group of drugs in this patient as you can. How might you go about reducing these medications?

Polypharmacy Polypharmacy means “many drugs”. The use of more medication than is clinically indicated or warranted. 5 or more drugs, 7 or more drugs… risk is 9 or more.

Why oh why oh why? The elderly use more drugs because illness is more common in older persons. Cardiovascular disease Arthritis Gastrointestinal disorders Bladder dysfunction

How Bad Can It Be? Elderly = 12% of population but 32% of prescriptions * Elderly women take, on average, 5.7 prescription drugs plus 3.2 over-the-counter medicines + Average American senior spends at least $211/year for pharmaceuticals.^ WOW! * Arnett. Health Care Financing Review 1990, Gupta Clin Therapeutics 1996, Golden JAGS 1999 + Everitt Arch Int Med 1986 , Gallagher J Clin Pharmacother 2007 ^Thomas Health Affairs 2001

What’s the big deal? Polypharmacy leads to: More adverse drug reactions Decreased adherence to drug regimens Adverse patient outcomes Poor quality of life High rate of symptomatology (Unnecessary) drug expense

Adverse Drug Reactions The most consistent risk factor for adverse drug reactions is: number of drugs being taken Risk rises exponentially as the number of drugs increases.

Number of medications taken Prybys et al, Emerg Med Rep 2002

Profile At Risk: Age > 85 years Estimated Creatinine Clearance < 50 mL/min Low body weight or low BMI (<22) More than 6 chronic diseases Prior adverse drug events Taking more than 12 doses of medication per day Taking 9 or more medications

Pharmacokinetics and Aging “What the Body Does to the Drug” Absorption Distribution Metabolism Excretion

Pharmacokinetics and Aging Distribution: Important Age-Related Changes: Decrease in Lean Body Mass and TBW Increased percentage Body Fat Increase in volume of distribution for lipophilic drugs, such as sedatives that penetrate CNS. Protein Binding changes are of modest significance for most drugs, especially at steady-state.

Pharmacokinetics and Aging Metabolism: Though liver function tests are unchanged with age, there is some overall decline in metabolic capacity. Decreased liver mass and hepatic blood flow Highly variable, no good estimation algorithm Minimal clinical manifestations

Pharmacokinetics and Aging Renal Excretion: Age-related decreased renal blood flow and GFR is well-established. Decreased lean body mass leads to decreased creatinine production.

Pharmacodynamics and Aging “What the Drug Does to the Body” Generally, lower drug doses are required to achieve the same effect with advancing age. Receptor numbers, affinity, or post-receptor cellular effects may change. Changes in homeostatic mechanisms can increase or decrease drug sensitivity.

(Potentially)Inappropriate Medications for Older Adults The Beers Criteria, aka Beers List Provides a list of medications that are generally considered inappropriate to the elderly (may cause more risk than benefit) Originally published in the Archives of Internal Medicine in 1991 and most recently updated in 2003.

Non-Adherence Non-adherence is a two-way street! Physician factors Patient factors

Polypharmacy & Non-adherence Patient Underreporting symptoms Use of multiple providers Use of others’ medications Physician Limited time for discussion, diagnostics Limited knowledge of geriatric pharmacology

Non-Adherence Strongest predictor of why non-adherence occurs is number of medications Rates estimated at 25-50% (that’s big!) Intentional about 75% of the time Changes in regimen made by patients to increase convenience, reduce adverse effects, or decrease refill expense

Factors that Contribute to Non-Adherence Large number of medications Expensive medications Complex or frequently changing schedule Adverse reactions Confusion about brand name/trade name Difficult-to-open containers Rectal, vaginal, SQ modes of administration Limited patient understanding

As the PCP… Annual Brown Bag At least yearly, and more often if indicated, ask elderly patients to bring in all medications they have at home. Prescription Over-the-counter Vitamins supplements Herbal preparations

Vitamins and Herbs Highly prevalent among older adults 77% in Johnson and Wyandotte county community dwelling elderly Generally not reported to the physician Some serious drug interactions possible: Warfarin, gingko biloba, vitamin E

MD: Why are you taking this? Patient: I don’t know… the doctor told me to… *scratches head*

The poor patient! Drug reactions in the elderly often produce effects that simulate the conventional image of growing old: unsteadiness drowsiness dizziness falls confusion depression nervousness incontinence fatigue malaise insomnia

With Great Power Comes Great Responsibility… Document and determine indication Prioritize Vital vs. optional Cure vs. relieve symptom Discuss with patient, caregiver Plan for medication reduction

You hold the key! Nine KEY Questions Is each medication necessary? Is the drug contrainidicated in the elderly? Are there duplicate medications? Is the patient taking the lowest effective dose? Is the medication intended to treat the side effect of another medications? Can I simplify a drug regimen? Are there potential drug interactions? Is the patient adherent? Is the patient taking an OTC medication, an herbal product, or another person’s medication?

Red Flag Meds High possibility of interactions!!! Amiodarone Beta Blockers Bile Acid Sequestrants Carbamazepine Cimetidine Digoxin Diuretics Erythromycin Fluoroquinolones Grapefruit juice Ketoconazole MAOIs Nitrates Phenobarbital Phenytoin Simvastatin Theophylline Warfarin

Meds Most Associated with Adverse Effects in the Elderly psychotropic drugs-benzodiazepines anti-hypertensive agents diuretics digoxin NSAIDS corticosteroids warfarin theophylline

Examples of Possible Substitutes Potentially Bad Elder-Friendly Diphenhydramine Loratidine, Fexofenedine, Cetirizine, Steroid nasal sprays Methyldopa Diuretics NSAIDs Acetaminophen, Rofecoxib, Celecoxib Diazepam Lorazepam (short acting)

Examples of Cover-ups Alpha adrenergic antagonists – for urinary retention associated with anticholingergics Antiemetics – for nausea with Digoxin Antitussives – for cough associated with Ace inhibitors Chronic use of Antacids, H2 receptor antagonists or PPI – for dyspepsia from ASA or NSAIDs Laxatives – for constipation from Verapamil Sedatives – for side effects from antidepressants

Prescribing Pearls Use single daily dose regimens Limit the use of PRN medications Consider all new medicines as a therapeutic trial Discontinue a drug if it is ineffective or intolerable adverse effects occur Provide legible written instructions Instruct caregivers as needed

Prescribing Pearls Attempt to prescribe a drug that will treat more than one existing problem Calcium channel blocker or Beta blocker to treat both hypertension and angina pectoris ACE-inhibitor to treat both hypertension, heart failure, and or for renal protection in diabetes Alpha-blocker to treat both hypertension and prostatism

Ways to Decrease Drug Costs Generics ok Change dosing regimen, e.g. one-a-day may be more expensive Older drugs, e.g. beta blockers, diuretics, acetaminophen Double duty drugs, e.g. beta and alpha blockers, ACE-inhibitors Avoid non-regulated products

Patient Education Use one pharmacist/pharmacy Use your PCP as intended…avoid seeing multiple physicians Do not use medications from others Report symptoms All medicines, even over-the-counter, have adverse effects Report all products used

Brown Bag Omega 3 fatty acid capsules Vitamin E Stelazine 2 mg @ hs Percocet q4 hr Propanolol 10 mg qd Aspirin 81 mg qd Vitamin B complex Lipitor 10 mg qd Metoprolol 50 mg bid Prilosec 20 mg qd Imipramine 25 mg qhs Fish oil capsules Propoxyphene/acetaminophen q6 hr prn Flurazepam 15 mg qhs Ranitidine 150 mg bid Tylenol PM, over the counter prn Digoxin 0.25 mg qd

Sorting Hat IMPORTANT SUBSTITUTE DO NOT NEED DUPLICATES BARGAIN DO NOT WANT!

Sorted! IMPORTANT SUBSTITUTE DO NOT NEED DUPLICATES BARGAIN Aspirin 81 mg qd Lipitor 10 mg qd Metoprolol 50 mg bid Percocet q4 hr SUBSTITUTE Flurazepam 15 mg qhs Stelazine 2 mg @ hs DO NOT NEED Omega 3 fatty acid capsules Vitamin E Vitamin B complex Fish oil capsules DUPLICATES Propanolol 10 mg qd Propoxyphene/acetaminophen Ranitidine 150 mg bid BARGAIN Prilosec 20 mg qd Digoxin 0.25 mg qd DO NOT WANT! Tylenol PM Imipramine 25 mg qhs

The Brown Bag IMPORTANT SUBSTITUTE DO NOT NEED DUPLICATES BARGAIN Aspirin 81 mg qd Lipitor 10 mg qd Metoprolol 50 mg bid Percocet q4 hr SUBSTITUTE Flurazepam 15 mg qhs Stelazine 2 mg @ hs DO NOT NEED Omega 3 fatty acid capsules Vitamin E Vitamin B complex Fish oil capsules DUPLICATES Propanolol 10 mg qd Propoxyphene/acetaminophen Ranitidine 150 mg bid BARGAIN Prilosec 20 mg qd Digoxin 0.25 mg qd DO NOT WANT! Tylenol PM Imipramine 25 mg qhs

The Brown Bag IMPORTANT SUBSTITUTE DO NOT NEED DUPLICATES BARGAIN Aspirin 81 mg qd Lipitor 10 mg qd Metoprolol 50 mg bid Prilosec 20 mg qd SUBSTITUTE Flurazepam 15 mg qhs Stelazine 2 mg @ hs TRAZODONE? DO NOT NEED Omega 3 fatty acid capsules Vitamin E Vitamin B complex Fish oil capsules DUPLICATES Propanolol 10 mg qd Propoxyphene/acetaminophen Ranitidine 150 mg bid BARGAIN Digoxin 0.25 mg qd Percocet q4 hr DO NOT WANT! Tylenol PM Imipramine 25 mg qhs

The Brown Bagette! Aspirin 81 mg qd Lipitor 10 mg qd Metoprolol 50 mg bid Percocet q4 hr Trazodone 25 mg QHS Prilosec 20 mg qd Digoxin 0.25 mg qd