Polypharmacy:OptimizingMedicationUsethrough

DeprescribingDr.LalithaRaman-Wilms,BScPhm,PharmD,FCSHP

CollegeofPharmacy,UniversityofManitobaMarch9,2018

PresenterDisclosure• LalithaRaman-Wilms

• Relationshipswithcommercialinterests:None– CurrentGrants/ResearchSupport:

– MinistryofHealthandLong-TermCare(MOHLTC),Ontario– CanadianFoundationforPharmacy– InnovationFund

MitigatingPotentialBias• NotApplicable

LearningObjectives• Describetheclinicalimplicationsofpolypharmacyin

geriatriccancerpatients,includingadversedrugreactionsanddruginteractions.

• Describetoolsandstrategiestoscreenolderadultsforpolypharmacy.

• Discussstrategiestooptimizemedicationuseintheelderly.• Discusseducationalstrategiesforsafemedicationuse in

olderadults.

“Thestatisticsarestaggering. Fortypercentofthoseover85inCanadaaretakingatleast10medications.Two-thirdsofthoseover65aretakingatleastfive medications.”

Dr.CaraTannenbaum,aScientificDirectorwiththeCanadianInstitutesofHealthResearch,andtheDirectorofthe CanadianDeprescribingNetwork,andhercolleagueshavebeenworkingtoraisetheprofileoftheoverprescribingproblem.

Terminology• Polypharmacy• MedicationOptimization• PotentiallyInappropriatemedications(PIM)– associatedwithnonadherence,adversedrugreactions(includingdruginteractions),riskforfalls,medicationerrors,hospitalizationandmortality

DRUGTHERAPYCONSIDERATIONSINTHEELDERLY

• Reducedkidneyfunction– greatertoxicitywithrenallyexcreteddrug(e.g.digoxin)

• Changesinliverfunction– longerhalf-lifefordrugsmetabolizedbycytochromeenzymes(e.g.flurazepam)

• GreatersensitivitytoCNS;greateradditiveeffects(e.g.antidepressants)

• Increaseinfat:musclemass(e.g.diazepam)

Clin Geriatr Med 2012;28: 273–286.Drugs Aging 2009;26(12):1039-48.

Clinicalimplicationsofpolypharmacyinolderpatientswithcancer…

• Associatedwith:– Post-operativecomplications(deGlasetal.2013)– Increasedlengthofstay(abdSx)(Badgwelletal.2013)– Grade3-4Chemotherapy-relatedtoxicity(Hamakeretal.2014)

– Loweroverallsurvival(Freyeretal.2005)

• Almost50%ofptsmod-severepotentialdrugissuespriortostartofcancerTx(CanCancerCentre- Quebec)

• Druginteractions:pre-existingmedsandcancerTxin1/3pts;newmedsusedforsupportivecare

Polypharmacyandpotentiallyinappropriatemedicationuseingeriatriconcology.JGeriatrOncol.2016;7(5):346-353Thelancet.com/oncology;2011;v12:1249-1257

DrugInteractions• Pharmaceutical – onedrugmayphysicallybindwithanotherdrugwhentakentogether

• Pharmacokinetic – onedrugaffectstheabsorption,distribution,metabolismorexcretionofanother

• Pharmacodynamic – interactionatsiteofaction– areceptororphysiologicsystem

ExamplesofDrugInteractions– Tamoxifen-fluoxetine/paroxetine– reducedconversionoftamoxifentoactivemetabolite

– Paclitaxel-warfarin– increasedanticoagulanteffect– Cisplatin-phenytoin– decreasedphenytoinconc

Ø Clinicalsignificance&managementØGreater#ofdrugs,higherrisk

AdverseDrugReactions(ADRs)• Adversedrugreaction– aresponsetoadrugwhichisnoxious

andunintendedandwhichoccursatdosesnormallyused(WHO2005)

• ADRinadults:corticosteroids,antibiotics,anticoagulants,antineoplasticandimmuno-suppressivedrugs,CVdrugs,NSAIDs,andopiates

• usuallyrelatedtothecardiovascular,renalorCNSsystems• Commondrug-relatedissuesintheelderly:cognitivechanges,

falls,urinaryincontinence,constipation

https://www.accp.com/docs/bookstore/psap/2015B2.SampleChapter.pdf

Continuingmedications

BENEFIT RISK

- PotentialADR- Frail,elderly- #ofmedications(Rx,

OTC,vitamins)- Adherenceissues

- ClearIndication- Evidencefor

effectiveness

Considerabalancebetweenbenefitsandharmsofmedications,takingintoaccountpatient’svaluesandgoals:

Deprescribing”Medicationsthatweregoodthen,mightnotbethebestchoicenow.Deprescribingispartofgoodprescribing– backingoffwhendosesaretoohigh,orstoppingmedicationsthatarenolongerneeded.”

“Deprescribingistheplannedandsupervisedprocessofdosereductionorstoppingofmedicationthatmaybecausingharmornolongerbeprovidingbenefit.”

https://deprescribing.org/what-is-deprescribing/

Deprescribingdecisions

BENEFITSPOTENTIALHARMS

• Adversewithdrawalreactions

• Worseningofunderlyingcondition

• Patient-familyanxiety

- Decreaseinfalls- Improvementin

cognition- Improvementin

psychomotorfunct- ERvisits,#drugs- Adherence,QoL

• Considerabalancebetweenbenefitsandpotentialharmsofdeprescribingmedications,takingintoaccountpatient’svaluesandgoals:

Medicationsthatmayrequiretapering• Antidepressants

(e.g.citalopram,venlafaxine)• Anticonvulsants(antiseizure

meds)• Antipsychotics• Baclofen• Benzodiazepines&Zdrugs• opioids

• Beta-blockers(e.g.metoprolol)

• CalciumChannelblockers(ifforangina)(e.g.verapamil)

• Cholinesteraseinhibitors(e.g.donepezil)

• Corticosteroids

AdverseDrugWithdrawalEvents

Ref:ThewaragainstPolypharmacy:ANewCost-EffectiveGeriatric-PalliativeApproachforImprovingDrugTherapyinDisabledElderlyPeople.DoronGarfinkel,SarahZur-GilandJoshuaBen-Israel.IMAJ2007;9:430–434

StrategiesforDeprescribing

Apracticalguidetostoppingmedicinesinolderpeople

Factorstoconsider:• Patientwishes• Clinicalindicationandbenefit• Appropriateness• Durationofuse• Adherence• Prescribingcascade

FourStepProcess1. Recognizetheneedtostop2. Reduceorstoponemedicineat

atime3. Considerifcanbestopped

abruptlyorshouldbetapered4. Checkforbenefitorharmafter

eachmedicinestopped

BestPractJ2010;27:10-23.https://bpac.org.nz/BPJ/2010/April/stopguide.aspx

Hardy&Hilmerfile:///Users/lraman/Downloads/Hardy_et_al-2011-Journal_of_Pharmacy_Practice_and_Research.pdf

Deprescribinginthelastyearoflife

5- stepDeprescribingProtocol(Scott2015)1. Comprehensivemedicationlist2. Assessmentofpatient’sclinicalstatus3. Assesseachdrugforeligibilitytobediscontinued

– isitindicated?– Considercurrent/futurebenefitsvsharms– patientgoalsandpreferences

4. Prioritizedrugsfordiscontinuation5. Monitoringandfollow-up

JAMA Intern Med 2015. doi:10.1001/jamainternmed.2015.0324

Elementsofadeprescribingprocess• Collectacompleteandcomprehensivemedicationhistory• Assessoverallriskofharmandbenefitandindividualpatientfactors

whichmayaffectdeprescribing• Identifypotentiallyinappropriatemedications• Decide onmedicationwithdrawal(shared-decisionmaking)• Plantaperingorwithdrawalprocessandmonitoringanddocumentation

and communicationtoallpersonsrelevanttocare• Conductmonitoringandsupport• Documentation

ReeveEetal.EurJIntMed;2017.http://www.ejinme.com/article/S0953-6205(16)30450-2/pdf

ToolstoidentifyPIMs• BeersCriteria– AmGerSoccriteriaforPIMuseinolderadults

• START- ScreeningToolofOlderPersonsPrescriptions/STOPP- ScreeningTooltoAlerttoRightTreatment

• OncPaldeprescribingguideline(palliativecarepatients)• AnticholinergicRiskScalehttps://www.ncbi.nlm.nih.gov/pubmed/26446832https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339726/SupportCareCancer(2015)23:71-78

Deprescribing.org

Patientinvolvement“Morethan90%ofpatientsarewillingtostopamedicationiftheirdoctorsaysitispossible”(JAGS)

• Patienteducation• Informed-decisionmaking

Managingpolypharmacyina77-year-oldwomanwithmultipleprescribers.BarbaraFarrellBScPhmPharmD,VéroniqueFrenchMerkleyMD,WadeThompsonHBSc.CMAJ,October1,2013,185(14)

Medicationreview• Reducedcognition

– MaybecontributedtobyanticholinergicloadandCNSdepressants(diltiazem,furosemide,amitriptyline,cyclobenzaprine,carbamazepine,morphine,oxazepam)

– Maynotrequiretreatmentwithgalantamineoncemedicationcontributorstapered

• Lowbloodpressureandorthostatichypotension(andfrequentfalls)– Maybecontributedtobycardiovascularmedications:Nitroglycerinpatch,Furosemide,

Amlodipine,Acebutolol,Quinapril,Diltiazem

Managingpolypharmacyina77-year-oldwomanwithmultipleprescribers.BarbaraFarrellBScPhmPharmD,VéroniqueFrenchMerkleyMD,WadeThompsonHBSc.CMAJ,October1,2013,185(14)

Managingpolypharmacyina77-year-oldwomanwithmultipleprescribers.BarbaraFarrellBScPhmPharmD,VéroniqueFrenchMerkleyMD,WadeThompsonHBSc.CMAJ,October1,2013,185(14)

ConsiderationsindeprescribingBarriers

• Patientcomplexity(polypharmacy,multiplecomorbidities)

• Prescribercomplexity(multipleprescribers)

• HCPperceptionofpatient/care-giverattitudes

• Safetyconcerns:adversedrugwithdrawal,returnofmedicalcondition,preventativemedicines,

Enablers• Self-efficacy– useofguidelines• Teamapproach• Collaboration– MD-Phm• Easytousetools/algorithms• Patientengagement• Effectivecommunication

DrugTherapyReview• ArethepatientsmedicationsINDICATED?• IsitEFFECTIVE?Considerdose,route,formulation,duration

• IsitSAFE forthepatient?Considercontraindications,druginteractions,potentialadversedrugeffects

• CanpatientADHEREtotherapy?Sizeofthemedication;frequency;cost

Keypoints• Carryoutregularmedicationreviews• Indicationfordrugtherapy• Toensuresafe&effectivedeprescribing:– Patientinvolvementindecisionmakingandinmonitoring– Collaborativeteamapproach

• Considerwhenandhowmedicationsshouldbetapered

• Discussoptionsfordrugbeingwithdrawn;considernon-pharmapproaches

References• Deprescribing resources:https://deprescribing.org/

• CanadianDeprescribing Network:https://deprescribing.org/caden/

References• Pharmacokineticsandpharmacodynamicchangesassociatedwithagingandimplicationsfordrugtherapy LCSera,ML

McPherson.Clin Geriatr Med 2012;28: 273–286.• Drugs Aging 2009;26(12):1039-48.• Polypharmacyandpotentiallyinappropriatemedicationuseingeriatriconcology.JGeriatrOncol.2016;7(5):346-353• Thelancet.com/oncology;2011;v12:1249-1257• ReeveEetal.EurJIntMed;2017.http://www.ejinme.com/article/S0953-6205(16)30450-2/pdf• https://www.ncbi.nlm.nih.gov/pubmed/26446832• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339726/• SupportCareCancer(2015)23:71-78• JAMA Intern Med 2015. doi:10.1001/jamainternmed.2015.0324• DeprescribingforolderpatientsChristopherFrankMD,EricaWeirMDMSc.CMAJ,December9,2014,186(18)• ThewaragainstPolypharmacy:ANewCost-EffectiveGeriatric-PalliativeApproachforImprovingDrugTherapyinDisabled

ElderlyPeopleDoronGarfinkel,SarahZur-GilandJoshuaBen-Israel.IMAJ2007;9:430–434• Managingpolypharmacyina77-year-oldwomanwithmultipleprescribers.BarbaraFarrellBScPhmPharmD,Véronique

FrenchMerkleyMD,WadeThompsonHBSc.CMAJ,October1,2013,185(14)

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