GERIMTG-Presentation-14-HAYWARDArthur-Polypharmacy … · Polypharmacy and Deprescribing in Older...

10/10/2016

1

MEDICARE CARE DELIVERY

Polypharmacy and Deprescribingin Older Adults

Oregon Geriatrics SocietyOctober 9, 2016

Arthur Hayward, MD, MBA

Internist and Geriatrician, Kaiser Permanente Northwest

| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.2 October 10, 2016

Session Objectives

1. Identify examples of polypharmacy

2. Recognize the particular risks of polypharmacy in the elderly

3. Apply deprescribing algorithms

10/10/2016

2


Case Histories

1. 45 yo ♂♂♂♂ on opioids for chronic pancreatitis reports his wife died unexpectedly.

2. 80 yo retired ♂♂♂♂ math teacher with dementia has become a “zombie” after entering a nursing home.

3. 74 yo ♀♀♀♀diabetic in ED for falls has HGBA1C of 6%.

4. Wife says her 79 yo mate won’t take all his medicines.

MEDICARE CARE DELIVERY

William Osler, 1849 - 1919

“Man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs. The desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures.”

10/10/2016

3


Brief History of Polypharmacy

Drugs perform miracles

Drugs are widely prescribed

Drugs are too widely prescribed

Harms result

Deprescribing reduces polypharmacy


Outline

1. Signs of polypharmacy2. Altered risk/benefit in older adults3. Solution: Deprescribe?4. Signs of the deprescribing era 5. Benefits of deprescribing

10/10/2016

4


1. Signs of polypharmacy

� Reflex prescribing

� Pharmaceutical hype

� Increased volume, costs, ADEs

� Backlash


� Failure to consider alternatives� Misapplying guidelines� Mistaking ADEs for new conditions

Reflex Prescribing

Huseyin Naci, John P A Ioannidis. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5577

10/10/2016

5

Non-pharma treatment alternativesFor… A. Not… B. But…

Back pain NSAIDs Cold and hot compresses

Insomnia Zolpidem Sleep hygiene

Urinary urgency Ditropan Pelvic floor exercises

Depression SSRI’s Cognitive behavioral Rx

Dementia “behaviors” Antipsychotics Environmental change

Anxiety Benzo’s Stress reduction activity

Adapted from KP Colorado Clinical Practice Guideline “Polypharmacy in the Elderly”


Statin use in adults older than 79

August 24, 2015. doi:10.1001/jamainternmed.2015.4302

10/10/2016

6

The Drug Cascade

Oxybutynin

Hip fracture

Fall

Orthostasis

Hip pain

Ibuprofen

HTN

HCTZ

Urinary Retention

Terazosin

A vicious Drug-ADE Cycle

Start here

Rochon P, Gurwitz J. Optimising drug treatment for elderly people: the prescribing cascade. BMJ, 1997;

315:1096-9

10/10/2016

7


Pharmaceutical hype

�Product promotion

�Choice of product

�Narcotic epidemic

“Who is responsible for the pain pill epidemic?” in The New Yorker 11/8/2013.

Inducements

| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

14 October 10, 2016

10/10/2016

8

Date of download: 8/2/2016Copyright © 2016 American Medical

Association. All rights reserved.

From: Pharmaceutical Industry–Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries

JAMA Intern Med. 2016;176(8):1114-10. doi:10.1001/jamainternmed.2016.2765

Target branded drugs

as a percentage of all

filled prescriptions in

the drug class.


Opioid (over)use

10/10/2016

9

Narcotic drugs more lethal than autos

New York Times, December 18, 2015


Pharma Promotion of Opioid Use

� Opioids have been aggressively and misleadingly marketed to physicians1

� Federal bodies and state medical boards received funds to promote pain relief 2

� Experts with pharma connections have rallied to criticize CDC proposed guidelines3

1 Van Zee A. The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health 2009;99:221-2272“Who is responsible for the pain pill epidemic?” in The New Yorker 11/8/2013. 3 AP wire services 1/31/2016 report on Interagency Pain Research Coordinating Committee

10/10/2016

10


� Deaths from prescription drug overdose have quadrupled since 2000.

� Opioids can worsen pain and functioning.

� Risks increase with dose increases.

� Use of heroin and illicitly produced Fentanyl has increased.

� CDC recommends non-pharmacologic approaches.

CDC assessment of opioid use

CDC Guideline with comment NEJM March 15, 2016 DOI: 10.1056/NEJMp1515917CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep 2016;65(RR-1:1-49


Volume

IMS Health Inc. data cited by Henry Kaiser Family Foundation“Drugmakers…” article. Wall Street Journal. Oct 3, 2016

• Increased numbers of prescriptions (4 B/y)

• Increased ADEs• Increased drug costs

($259B) ($329.1B)

10/10/2016

11

% of US adults reporting use of any and of > 5 drugs per day during preceding 30 days by age


21 October 10, 2016

NHANES data reported by Kantor, E, et al. JAMA November 3, 2015 Volume 314, Number 17


22 October 10, 2016

Data from the National Social Life, Health and Aging Project. College of Pharmacy, U of Chicago. JAMA Intern Med. doi:10.1001/jamainternmed.2015.8581 Published online March 21, 2016.

Findings:• Use of any med 84.1 � 87.7%• Use of >/= 5 meds 30.6 � 35.8%• Use of dietary supplements 51.8 � 63.7%• Risk of potential major drug-drug interaction 8.4 �15.1%

National Social Life, Health and Aging Project

Changes in Use of Drugs, OTCs, and Supplements 2005 to 2011

10/10/2016

12

Robin Hood Profiteering

The New Yorker January 4, 2016

How does epinephrine become a $1B drug?


Sunday Business SectionNew York TimesSeptember 4, 2016

Heather Bresch, Chief Executive, Mylan Pharmaceuticals

10/10/2016

13

The “Other” Drug Problem


The OregonianLIVING HEALTHLIVING HEALTHLIVING HEALTHLIVING HEALTH

Friday, Sept. 9, 2016


Signs of polypharmacy

Consumer mistrust and backlash

10/10/2016

14


2. Risk/Benefit increases in adults >/= 65

� Changes in metabolism and pharmacokinetics/dynamics

� More conditions/ more guidelines/ more prescribers

� More side effects1 / “drug cascade” to treat side effects

� Less time to benefit

� Expense of polypharmacy (estimated ~ $50B/y in US)2

� Multiple meds: inconvenience, burden, misery

1. Patterson SM, Cadogan CA, Kerse N, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014;10:CD008165.2. CMMS estimate cited in Lyles A, Culver N, Ivester J, Potter T. effects of health literacy and polypharmacy on medication adherence. Consult Pharm. 2013;28:793-799.


3. Solution: Deprescribe?

� Pharmacists play a leading role.

� Deprescribing algorithms exist1,2,3

Deprescribing is the process of tapering or

stopping drugs, aimed at minimizing

polypharmacy and improving patient

outcomes.1-- Ian Scott, et al, Brisbane, Australia

1. JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324 Published online March 23, 2015.2. Garfinkle. Arch Intern Med. 2010;170(18):1648-1654.

3. Frankenthal, et al. (STOPP/START) J Am Geriatr Soc 62:1658–1665, 2014.

10/10/2016

15

Survey results of PCPs:

• Lack of knowledge (39% not aware tight glucose control harms older adults)

• Fear of bad report card (42%)

• Fear of legal liability (25%)

• Not enough time to discuss (30%)

JAMA Intern Med. 2015;175(12):1994-1996. doi:10.1001/jamainternmed.2015.5950

Barriers to Deprescribing

Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults

Garfinkel D, Mangin DArch Intern Med. 2010;170(18):1648-1654

Protocol- indicated stop of 311 meds in 64 of 70 patients included

Result

Failure (re-started for original indication) 2%

Success (consented and not re-started) 81%

Compared to matched cohort

Global improvement in health 88%

Mortality benefit 14%

LESS IS MORE

10/10/2016

16


Improving drug therapy in elderly patients--the Good Palliative-Geriatric Practice algorithm

Garfinkel D, Mangin D. Arch Intern Med 2010;170:1648-1654.


Deprescribing simplified

1. Stop� Drugs that are unnecessary

� Duplicates

2. Shift� Safer for riskier

� Less costly alternative

� Non-drug treatment

3. Simplify� Dosing schedule

� Substitute one drug for two

10/10/2016

17

Simplified Geriatric Dosing


33 October 10, 2016

From The New Yorker, November, 2015

34| © Kaiser Permanente 2010-2011. All Rights Reserved.

October 10, 2016

Med Reconciliation and Polypharmacy

MedRec

Adherence

CorrectDirections

Correct Dose

CostEffective

Omissions

Renal DoseAdjustments

UnclearOrders

Drug-Disease Interactions

Drug-Drug Interactions

Duplication

Drugs to Avoid in the Elderly

Side EffectsOTCs/Herbals

Is drug still

appropriate?

Indication

Hajjar ER, Calfiero AC, Hanlon JT. Polypharmacy in Elderly Patients. Am J of Geriatric Pharmacother 2007; 5(4); 345-51

10/10/2016

18


Inside KP

Inside KP

� KPCO publishes polypharmacy intranet page

� KPGA addresses too-low HGBA1C and non-benzosedatives

� KPNW’s med rec aims to reduce polypharmacy

� DUM (Drug Utilization Management) program reverses trend in opioid prescribing

� MTM (Medication Therapy Management) stops unnecessary meds

Rita L. Hui, PharmD, MS; Brian D. Yamada, PharmD; Michele M. Spence, PhD;

Erwin W. Jeong, PharmD; and James Chan, PharmD, PhD. Impact of a Medicare MTM Program:

Evaluating Clinical and Economic Outcomes. Am J Manag Care. 2014;20(2):e43-e51

MTM

and

Comprehensive

Medication

Review

at KPAssociated with

- Lowered mortality

- Less hospitalization

10/10/2016

19


4. Signs of the deprescribing era

� Beers list, Choosing Wisely, Direct-to-consumer media efforts

� More published medical literature,

algorithms

� CMMS incentives

� A cultural shift

O’Mahony D, et al. STOPP/START criteria for potentially inappropriate

prescribing in older people: version 2. Age Ageing. 2015;44:213-218.

Jetha S. Polypharmacy, the Elderly, and Deprescribing. The Consultant

Pharmacist. September, 2015;30(9):527-32.


2015 Beers List Criteria Update

� 1991 Criteria originated by Mark Beers

� 2011 AGS (Am Geriatrics Society) charged with review and updates

� 2015 Revision1

– Alternatives proposed2

– Serious Drug-Drug interactions itemized

– Drugs requiring renal failure dosing are listed

– Shifts in emphasis result from literature review

1 DOI: 10.1111/jgs.13702 JAGS, October 20152 DOI: 10.1111/jgs.13807

10/10/2016

20


.

Polypharmacy in preventive cardiology1

Problem: Millions on CVD drugs* though proof of benefit lacking.� Short-term study results are extrapolated over decades.

� Results from young-old subjects are extrapolated to old-old.

� We have scant evidence on outcomes of drug withdrawals.

� Modern clinical practice differs from that when trials were conducted.

� Projections of benefits assume hazards are constant over time.

� Old-old adults may prefer different outcomes.

* Aspirin, beta-blockers, statins, ACE inhibitors

� How long should these drugs be continued?

1 J Am Coll Cardiol 2015;66:1273–85.


5. Benefits of Deprescribing

� Simplify care

� Reduce ADEs

� Reduce hospitalization

� Improve adherence

� Reduce costs

� Save lives

10/10/2016

21

Declining opioid use in KP 12/13 to 6/15


Case History Discussion

1. 45 yo on opioids for chronic pancreatitis reports unexpected death of his spouse.

2. 80 yo retired math teacher with dementia becomes a “zombie” after entering a NH.

3. 74 yo female diabetic in ED for falls has HGBA1C of 6%.

4. Wife says her 79 yo won’t take all his medicines.

10/10/2016

22

Bibliography

• InsidePatientCare.com Empowering Community Pharmacists as Health Consultants: Polypharmacy by Rebecca J. Mahan, PHARMD, CGP

• Brisbane, et al. Reducing Inappropriate Polypharmacy. JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324

• Tjia, et al. Use of Medications of Questionable Benefit…JAMA Intern Med. 2014;174(11):1763-1771. doi:10.1001/ jamainternmed.2014.4103

• Garfinkle D, Mangin D. Feasibility of a systemic approach… Arch Intern Med. 2010;170(18):1648-1654

• BMJ 2012:345:e6617 – Overtreatment – Is the USA’s problem ours too?

• BMJ 2012;345:e668 – Overtreament over here.

• Lam MP1, Cheung BM. The use of STOPP/START criteria as a screening tool for assessing the appropriateness of medications in the elderly

population. Expert Rev Clin Pharmacol 2012;5:187–197. (STOPP/START criteria)

• PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011. (STOPP/START

criteria)

• Frankenthal, et al. Intervention with the Screening Tool of Older Persons Potentially Inappropriate Prescriptions/Screening Tool to Alert Doctors to

Right Treatment Criteria in Elderly Residents of a Chronic Geriatric Facility: A Randomized Clinical Trial. J Am Geriatr Soc 62:1658–1665, 2014.

• Grounder, Celiine. “Who is responsible for the pain-pill epidemic?” The New Yorker, November 8, 2013.

• Moonen J et al. Effect of Discontinuing…JAMA Intern Med. doi:10.1001/jamainternmed.2015.4103 Published online August 24, 2015.

• Odden MC. (Editorial) JAMA Intern Med. Published online August 24, 2015. doi:10.1001/jamainternmed.2015.4309

• 2015 Beers Criteria Update: DOI: 10.1111/jgs.13702 and alternatives: DOI: 10.1111/jgs.13807

• Jetha S. Polypharmacy, the Elderly, and Deprescribing. The Consultant Pharmacist. September, 2015;30(9):527-32.

• Rochon P, Gurwitz J. Optimising drug treatment for elderly people: the prescribing cascade. BMJ, 1997; 315:1096-9

• Qato DM, et al. Changes in Prescription and Over-the-Counter Medication…2005 – 2011. JAMA Intern Med. Published online March 21, 2016.

doi:10.1001/jamainternmed.2015.8581

• Bemden MN.Deprescribing: An Application to Medication Management in Older Adults. Pharmacotherapy 2016;36(7):774–780) doi:

10.1002/phar.1776

Tools and collaborators

• http://www.medstopper.com

• http://www.open-pharmacy-research.ca/research-projects/emerging-services/deprescribing-guidelines

• https://clm.kp.org/wps/portal/cl/CO/result?url=/pkc/co/cpg/cpg/polypharmacy.html&category=Geriatrics&doctype=Guideli

nes&sdtype=Clinical&location=AdultCare&memberage=Adult%20Care&cntName=Polypharmacy%20in%20the%20Elderly

How to deprescribe

• (1) ascertain all drugs the patient is currently taking and the reasons for each one

• (2) consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention

• (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential

• (4) prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes

• (5) implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects.

JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324

GERIMTG-Presentation-14-HAYWARDArthur-Polypharmacy … · Polypharmacy and Deprescribing in Older...

Documents

Transcript of GERIMTG-Presentation-14-HAYWARDArthur-Polypharmacy … · Polypharmacy and Deprescribing in Older...