DEPRESCRIBING - CSIMcsim.ca/wp-content/uploads/documents/meeting2014/presentations/Oc… · Highly...
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DEPRESCRIBING
Phil St JohnCSIM Workshop
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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
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JAMA Editorial, March 19, 1910
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JAMA, 1937
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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
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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
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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
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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
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DEFINITIONS
Polypharmacy – depends on setting – initially four or more
Risk Factors Polyproblems Polydoctors Age Gender Low Social Position
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deprescribing is the cessation of long-term therapy, supervised by a clinician.
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Clin Geriatr Med 28 (2012) 237–253
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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
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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
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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
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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
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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?
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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?
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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?
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What is a prescribing cascade?
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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
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COMMON CASCADES
Anticholinergics and cholinergics
NSAIDS and antihypertensives
Ca antagonists and diuretics
Antipsychotics and antiparkinson agents
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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
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Meds
HCT 12.5 mg daily Tylenol plain prn Diazepam 10 mg at HS
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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
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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
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Added zopliclone
Is this safer?
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Transferred to Geriatrics
Osteoporosis work-up unremarkable
What would you do?
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Agreed to taper zopiclone
Attempted diazepam does reduction to 7.5 mg daily
Paged hourly from 10 to 1
Restarted
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Fell 8 days later and fractured two ribs
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Bush Vows To Wipe Out Prescription-Drug Addiction Among Seniors
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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
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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.
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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:
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Undercover Cop Never Knew Selling Drugs Was Such Hard WorkMARCH 5, 2003 | ISSUE 39•08
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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
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Falls OA Osteoporosis Prostate Cancer with retention and foley Macular Degeneration CRF Vascular Dementia
Dependent in BADLs Aggressive and violent behaviour
Atrial fibrillation
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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
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What medications are working in the opposite direction?
Would you streamline meds? How would you go about this?
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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
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Copyright restrictions may apply.Steinman, M. A. et al. JAMA 2010;304:1592-1601.
Selected High-Risk Drugs
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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
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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
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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
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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
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CONCLUSIONS
This is a complicated area
Need to think less about polypharmacy and more about appropriateness