Deprescribir en diabetes El flagrante caso de un señor anciano

Nicolas Martínez Velilla

Servicio de Geriatría

Complejo Hospitalario de Navarra

1. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (2003). Hypertension 42:1206-1252

2. American Diabetes Association. Standards of medical care for patients with diabetes mellitus (2002). Diabetes Care 25:S33-S49.

3. National Osteoporosis Foundation. Physician's guide to prevention and treatment of osteoporosis. Belle Mead, N.J.: Excerpta Medica,

4. Smith SC Jr, Blair SN, Bonow RO, et al. AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology (2001). Circulation 104:1577-1579

5. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the International Society for Heart and Lung Transplantation: endorsed by the Heart Failure Society of America (2001). Circulation 104:2996-3007

FLAGRANTE, DIABETES, ANCIANO

23 fármacosAspirina

IECAAtenolol

Bifosfonato x 7a, calcio, Vitamina DFurosemida+ Espironolactona

ISRSEstatina

3 antidiabéticosIAch+/-memantina +/- SCPD

LaxanteCorticoide vo + Corticoide inh

B-2+ anticolinérgicoAINE

Lorazepam

EJEMPLO: 85 años: HTA, DM, CI, depresión, osteoporosis, det cognitivo moderado, FAC, EPOC + GUÍAS CLÍNICAS → 21 fármacos (+ Hb A1c 6.5)

¿QUIÉN DE LOS SIGUIENTES ES FRÁGIL?

Alemán JJ, Artola S. Franch J, Mata M, Millaruelo JM, Sangrós FJ, et al. Recomendaciones para el tratamiento de la diabetes mellitus tipo 2: control glucémico. Diabetes Práctica. 2014;05:18-20.

JAMA Intern Med. 2015 Mar;175(3):356-62.

CASCADAS DE PRESCRIPCIÓN

AINE-hipertensión-hipotensor Amlodipino-edemas-diurético-hipoK Potasio- molestias GI- IBP Donepezilo-Incontinencia- oxibutinina Oxibutinina-deterioro cognitivo-donepezilo Amiodarona- temblor- propanolol Risperidona- parkinsonismo- dopa Betabloqueante-depresión-antidepresivo Sd confusional- haloperidol / anticolinérgico- RAO- perpetuación

ICC, HTA, CARDIOVASCULAR

DM

CÁNCER

DEMENCIA

EPOC/ASMA

PATOLOGÍA OSTEOARTICULAR

FA

AR

PARKINSON

ANEMIA

GOTAPSORIASIS

HIPOTIROIDISMOSUBCLINICO

ETEV

OBESIDAD

DEPRESIÓN

EPILEPSIA

HERRAMIENTAS PARA VALORACIÓN FARMACOLÓGICA DE

ANCIANOSCRITERIOS EXPLÍCITOS

BEERSSTOPP/STARTCRITERIOS DE MCLEODACOVE

CRITERIOS IMPLÍCITOSMEDICATION APPROPRIATENESS INDEXALGORITMO GOOD PALLIATIVE-GERIATRIC

PRACTICE

2012 AGS Beers Criteria - Categories1st Category 2nd Category 3rd Category

PIMs for older people:

• Pose high risks of adverse effects OR

• Appear to have limited effectiveness in older pts

AND

• There are alternatives to these medications

PIMs for older people:

• Who have certain diseases/disorders

– b/c these drugs may exacerbate the specified health problems

Use with caution in older adults

• May be associated with more risks than benefits in general

–However, may be the best choice for a particular individual if administered with caution

• 53 medications or medication classes that should be avoided in older adults

• 14 that should be used with caution

STOPP Criteria

Screening Tool of Older Persons’ potentially inappropriate Prescriptions

65 rules relating to the most common and the most potentially dangerous instances of inappropriate

prescribing in older people

O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, Barry P, O’Connor M, Kennedy J. STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age. European Geriatric Medicine. 2010 Jan 6; 1(1):45-51.

Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011 Jun 13;171(11):1013-9.

START CriteriaScreening Tool to Alert doctors to the Right

Treatment

22 rules relating to common instances of prescribing omission

O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, Barry P, O’Connor M, Kennedy J. STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age. European Geriatric Medicine. 2010 Jan 6; 1(1):45-51.

Medication Appropriateness Index1. Is there an indication for the drug?

2. Is the medication effective for the condition?

3. Is the dosage correct?

4. Are the directions correct?

5. Are the directions practical?

6. Are there clinically significant drug-drug interactions?

7. Are there clinically significant drug-disease/condition interactions?

8. Is there unnecessary duplication with other drugs?

9. Is the duration of therapy acceptable?

10. Is this drug the least expensive alternative compared with others of equal usefulness?

Arch Intern Med. Vol 166, March 27, 2006

Piensa más allá de los fármacos

Recuerda efectos a largo plazo

Vigila posibles efectos adversos

Prescripción estratégica

Implica a pacientes/cuidadores

Precaución con fármacos noveles

Expe

ctat

iva d

e vid

a

Tiem

po h

asta

ben

efici

oObjetivos de los

cuidados

Objetivos del

tratamiento

Fármaco MonitorizarBeta bloqueante FC, TA, CIDigoxina FC, palpitacionesDiuréticos (furosemida, HCTZ)

TA, edema, peso, disnea

IBP, Anti H2 Hiperacidez rebote, RGECorticoides Nauseas, debilidad, TAAnticolinérgicos Ansiedad, nausea, vómitos,

diarrea, mareoAntiparkinsonianos Rigidez, temblor, TAAntidepresivos (ISRS, ISRN, ADT)

Agudos: insomnio, inquietud, sudor, temblores, MEG Crónicos: depresión

Hipnóticos, bdz Insomnio rebote, inquietud, ansiedad, temblor

Derivados morfina Aumento dolor, alteración motilidad, insomnio, inquietud, ansiedad, diarrea

Antipsicóticos Alucinaciones, inquietud, agitación, insomnio

No precisan monitorización: bifosfonatos, estatinas, vitaminas, suplementosAAS, anticoagulanteAdemás: Quién, cómo, dónde

IECAAtenolol

Bifosfonato x 7a, calcio, Vitamina DDiurético, Espironolactona

ISRSEstatina

3 antidiabéticos-1 ADIAch+/-memantina +/- SCPD

LaxanteCorticoide vo + Corticoide inh

B-2+ anticolinérgicoAINE

LorazepamAspirina

FLAGRANTE, DIABETES, ANCIANO

23 fármacosAspirina

IECAAtenolol

Bifosfonato x 7a, calcio, Vitamina DFurosemida+ Espironolactona

ISRSEstatina

3 antidiabéticosIAch+/-memantina +/- SCPD

LaxanteCorticoide vo + Corticoide inh

B-2+ anticolinérgicoAINE

Lorazepam

EJEMPLO: 85 años: HTA, DM, CI, depresión, osteoporosis, det cognitivo moderado, FAC, EPOC → 21 fármacos + Hb A1c 6.5

THM Importancia de optimizar el tratamiento farmacológico,

especialmente en pacientes con polifarmacia, ancianos, frágiles o con expectativa de vida reducida

Deprescripción diabetes: CV y no CVAbordaje multidisciplinarCriterios implícitos y explícitos, abordaje global con

aspectos no solo médicos (VGI) Incertidumbre, necesidad de más estudios para

modelos de deprescripción y resultados relacionados con la salud

https://www.youtube.com/watch?v=53qIRRoFesAFacebook#deprescripcion #cascadaterapeutica

#polifarmacia #desrecetarJames McCormack @medmyths

https://twitter.com/polimedlabswww .choosing wisely.org/doctor-patient

-lists/american -geriatrics-societywww.choosingwiselycanada.orgEspaña; prevención cuaternariaDropbox, slideshare

MUCHAS GRACIAS

mvelilla@yahoo.com