DEPRESCRIBING

Phil St JohnCSIM Workshop

Conflict of Interest Disclosure

• Consultant for: none

• Speaker for: none

• Received grant/research support from: CIHR, MHRC, Riverview Foundation

• Received honoraria from: Co-chair Longterm care formulary, Winnipeg Regional Health Authority

JAMA Editorial, March 19, 1910

JAMA, 1937

KEY POINTS

Life is complicated

Need to enumerate problems, set goals of treatments, set acceptable trade offs and target therapy

Need to understand the patient and family goals

Functional status and frailty should be considered in treatment decisions

Start low, go slow, and be patient

Can dither and change course in some cases, not in others

OLDER PEOPLE Are very heterogeneous

Highly unpredictable drug effects On average, have more things wrong with them Have more doctors On average, have higher fat/water ratios

Generally, longer half-life of lipophilic drugs On average, have lower renal function Generally value functional status more than life

extension Have been on medications for longer On average, live less long

ALL PEOPLE Generally don’t like side-effects Generally like symptomatic benefits Don’t adhere to their medications Adhere better to simple regimens Don’t always tell the complete truth

Have friends and families

Read the newspapers and/or internet

Should know what we are thinking

DEFINITIONS

Polypharmacy – depends on setting – initially four or more

Risk Factors Polyproblems Polydoctors Age Gender Low Social Position

deprescribing is the cessation of long-term therapy, supervised by a clinician.

Clin Geriatr Med 28 (2012) 237–253

A GENERAL APPROACH

Enumerate the problems in all domains Set goals and a plan for them Prioritize and balance Understand patient and family goals Determine the “Global” approach

Get an accurate and up to date medication list Find out how they got there Determine if and how they are taking them Determine risks and benefits

Set up a treatment plan May involve starting new meds May involve stopping and or/tapering

Should know the guidelines, but not always follow them all the time in all people

Should look things up

Should take our time Tapering off (Start low, go slow – in reverse)

A process not an event

Collaborative approach Family Friends Pharmacists Nursing Other physicians

But should know who is in charge

Mrs S

93 year old Assisted Living resident Previous IADL and some ADL dependence Past History of falls, fractured hip, macular

degeneration, cataracts, IHD (CABG), CVA, falls, atrial fibrillation, hypertension, CHF (normal systolic fcn), renal insufficiency, osteoporosis, vascular dementia, urinary incontinence

Fall with hip fracture Transferred for rehab

MEDS

Metoprolol 75 mg BID Ramipril 5 mg BID ISDN 15 mg TID ASA 325 mg daily Plavix 75 mg daily Lasix 80 mg daily Amlodipine 5 mg daily Donepezil 10 mg daily Ciprofloxacin 500 mg po

daily Omeprazole 20 mg daily

Tylenol 3 PRN Morphine 2.5- 5.0 prn Fentanyl patch 50 mcg daily Gabapentin 100 mg tid Oyxbutinin 5 mg bid Risperidone 1 mg BID Alendronate 70 mg weekly Vitamin D 400 units daily Zoplicone 7.5 mg QHS LMWH – should she go

back on warfarin?

CAN WE FIX THIS?

Which medications are inappropriate? Which medications can be stopped? Which medications must be tapered? Which medications directly antagonize each

other? Should she be on any other medications? Are the doses correct?

QUESTIONS

Did she have a UTI? What happened two days after she was

admitted to non-teaching medicine? When did her peripheral oedema start? Why? Why was she itchy? How would you go about medication

reduction?

What is a prescribing cascade?

PRESCRIBING CASCADE

DRUG 1

DRUG 2

Adverse drug effect—misinterpreted as a new medical condition

-

Adverse drug effect—misinterpreted as a new medical condition

Slide 26

COMMON CASCADES

Anticholinergics and cholinergics

NSAIDS and antihypertensives

Ca antagonists and diuretics

Antipsychotics and antiparkinson agents

CASE 3

90 year old man Retired bombardier Living independently in a house in the

community Previous history hypertension, osteoarthritis

and poor sleep Fell and complained of pain in his back Admitted to family medicine

Meds

HCT 12.5 mg daily Tylenol plain prn Diazepam 10 mg at HS

Admitted to family medicine with L1 fracture

Started on heparin S/Q, Vitamin D, Calcium, Calcitonin, Tylenol 975 mg po tid, and Morphine 2.5 mg Q1H for breakthrough

Attempted to taper his Valium to 7.5 mg every night

Paged at 10, 11, 12 and 1h

Started back on original dose

Fell and fractured hip three days later

Transferred to teaching hospital with ortho

Added zopliclone

Is this safer?

Transferred to Geriatrics

Osteoporosis work-up unremarkable

What would you do?

Agreed to taper zopiclone

Attempted diazepam does reduction to 7.5 mg daily

Paged hourly from 10 to 1

Restarted

Fell 8 days later and fractured two ribs

Bush Vows To Wipe Out Prescription-Drug Addiction Among Seniors

Pooled odds ratios in relation to not using benzodiazepines in studies aimed at withdrawal from these drugs at post-intervention.a.

Gould R L et al. BJP 2014;204:98-107

©2014 by The Royal College of Psychiatrists

Conclusions

Supervised benzodiazepine withdrawal augmented with psychotherapy should be considered in older people, although pragmatic reasons may necessitate consideration of other strategies such as medication review.

Date of download: 9/24/2014 Copyright © 2014 American Medical Association. All rights reserved.

From: Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons

Arch Intern Med. 2009;169(21):1952-1960. doi:10.1001/archinternmed.2009.357

Medications and falls: meta−analysis results. Odds ratios and 95% credible intervals or 95% confidence intervals on a logarithmic scale for individual or pooled study data for each class of medication. Outcome is occurrence of at least 1 fall. NSAIDs indicates nonsteroidal anti-inflammatory drugs.

Figure Legend:

Undercover Cop Never Knew Selling Drugs Was Such Hard WorkMARCH 5, 2003 | ISSUE 39•08

Mr O

87 year old man, living in nursing home Relocated to rehab unit when NH evacuated Previous history HBP DM2 IHD – stents and CABG CHF –class III - IV Arrest with ICD PVD

Falls OA Osteoporosis Prostate Cancer with retention and foley Macular Degeneration CRF Vascular Dementia

Dependent in BADLs Aggressive and violent behaviour

Atrial fibrillation

MEDS

Metoprolol 50 mg poBID

Warfarin Clopidogrel 75 mg

daily ASA 81 mg daily Glyburide 5 mg daily ISDN 15 mg tid Tylenol prn

Finasteride Ditropan 5 mg bid Flomax 0.4 mg daily Lasix 80 mg po BID Donepezil 5 mg daily Risperidone 5 mg BID

What medications are working in the opposite direction?

Would you streamline meds? How would you go about this?

COMMON DRUG-DRUG INTERACTIONS

Combination RiskACE inhibitor + diuretic Hypotension, hyperkalemia

ACE inhibitor + potassium Hyperkalemia

Antiarrhythmic + diuretic Electrolyte imbalance, arrhythmias

Benzodiazepine + antidepressant, antipsychotic, or benzodiazepine

Confusion, sedation, falls

Calcium channel blocker + diuretic or nitrate

Hypotension

Digitalis + diuretic ArrhythmiasSlide 52

Copyright restrictions may apply.Steinman, M. A. et al. JAMA 2010;304:1592-1601.

Selected High-Risk Drugs

COMMON DRUG-DISEASEINTERACTIONS

Obesity alters VD of lipophilic drugs

Ascites alters VD of hydrophilic drugs

Dementia may ↑ sensitivity, induce paradoxical reactions to drugs with CNS or anticholinergic activity

Renal or hepatic impairment may impair detoxification and excretion of drugs

BEFORE PRESCRIBINGA NEW DRUG, CONSIDER:

Is this medication necessary? What are the therapeutic end points? Do the benefits outweigh the risks? Is it used to treat effects of another drug? Could 1 drug be used to treat 2 conditions? Could it interact with diseases, other drugs? Does patient know what it’s for, how to take it, and what

ADEs to look for?

Slide 55

PRINCIPLES OF DRUG REVIEW

Ask patient to bring in all medications (prescribed, OTC, supplements) for review

LOOK AT THEIR MEDS LOOK AT AIDES DPIN

Ask about side effects and screen for drug and disease interactions

Look for duplicate therapies or pharmacologic effect

Eliminate unnecessary medications and simplify dosing regimens

Get collateral – family, other doctors, pharmacist

NONADHERENCE May be as high as 50% among older

patients

May result from clinician’s failure to consider patient’s financial, cognitive, functional status

May result from patient’s beliefs and understanding of drugs and diseases

Slide 57

CONCLUSIONS

This is a complicated area

Need to think less about polypharmacy and more about appropriateness