Stephanie Nichols, Pharm.D., BCPS, BCPPAssociate Professor – Husson University School of PharmacyClinical Pharmacist – Psychiatry & Adult Inpatient MedicineNicholss@Husson.edu

American College of Physicians - Maine ChapterAutumn Meeting in Bar Harbor

September, 2014

Define polypharmacy and recall it's prevalence

Illustrate why recognition and management of polypharmacy is important

Demonstrate strategies to avoid polypharmacy

Assess high risk polypharmacy situations and formulate a plan to initiate pharmacological debridement

Employ strategies to improve medication adherence in patients with a high pill burden

X+ chronic daily medications?› OTCs/Herbals› Ex. HF or COPD

“High Risk Polypharmacy”› Ex. 2+ narcotics, 2+ benzos, 3+ oral

hypoglycemics 2+ drugs in the same class?

More drugs prescribed than warranted clinically ?

› “Prescribing cascade”

Kaufman, Kelly, Rosenberg, Anderson, Mitchell. JAMA 2002;287:337-44.

Mean number of meds per patient = 13.5

Nearly a quarter had >16 meds

OR 4.75 (95% CI: 1.0 – 11.2) for polypharmacy with 2+ high risk diagnoses› COPD, CA, DM, CHF, CAD

Rohrer JE et al. J Prim Care Community Health. 2013 Apr 1;4(2):101-5.

Gamble JM et al. Therapeutics and Clinical Risk Management 2014:10 189–196

Slabaugh, Maio, Templin, Abouzaid. Drugs & Aging. 2010; 27(12):1019-1028.

Viktil GK, Blix HS, Moger TA, Reikvam A. Brit J of Clin Pharmacol 2006;63(2):187-95.

Low Adherence Falls and Fractures ED visits and admissions Increased healthcare costs Reduced quality of life Increased mortality

Lyles, Culver, Ivester, Potter. Consult Pharm. 2013 Dec;28(12):793-9.Lai, Liao, Liao, Muo, Liu, Sung. Medicine (Baltimore) 2010;89(5):295.

Circulation. 2010; 122:A14790

4.2% of admissions due to ADRs

Pedros C et al. Eur J Clin Pharmacol. 2014 Mar;70(3):361-7.

Number of Drugs

Odds Ratio of ADR

Admission

95% CI

≤ 2 1.0 (Reference)

3 - 5 5.07 2.71 – 9.59

6 – 9 5.9 3.16 – 11.0

10 + 8.94 4.73 – 16.89

Pedros C et al. Eur J Clin Pharmacol. 2014 Mar;70(3):361-7.

Safety Tolerability Effectiveness Price Simplicity

Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20.

Pocket Card› http://www.americangeriatrics.org/files/doc

uments/beers/PrintableBeersPocketCard.pdf

AGS iGeriatrics App - $2.99

2003

STOPP - Screening Tool of Older People’s potentially inappropriate Prescriptions› 65 recommendations

START - Screening Tool to Alert doctors to the Right Treatment› 22 recommendations

http://www.ngna.org/_resources/documentation/chapter/carolina_mountain/STARTandSTOPP.pdfGallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. Int J Clin Pharmacol

Ther. 2008 Feb;46(2):72-83.

• Rudolph, Salow, Angelini, McGlinchey. Arch Intern Med. 2008;168(5):508.• Carnahan, Lund, Perry, Pollock, Culp. J Clin Pharmacol 2006;46:1481-6.• Boustani, Campbell, Munger, Maidment, Fox. Aging Health 2008;4:311-20.• http://www.indydiscoverynetwork.org/resources/antichol_burden_scale.pdf

Find an indication for each drug› Goal of therapy?

Are we using the best drug for each problem/disease/disorder in this patient?› Eg. HTN and beta blockers

Schedule a “brown bag” appointment periodically

When switching from one agent to another, or stopping an agent completely…

…ask the community pharmacy to d/c the old prescription

Periodically compare medication lists with the pharmacist/pharmacy

When new symptoms emerge, particularly in geriatric patients, think about medication AEs

http://www.acpm.org/?MedAdherTT_ClinRefhttp://www.iarx.org/documents/PrinciplesOfHealthcare2010.pdf

S implify regimen I mpart knowledgeM odify patient beliefs and human behavior P rovide communication and trust L eave the biasE valuate adherence

Atreja A, Bellam N, Levy S. Medacapt Gen Med. 2005:7(1): 4.

Daily or BID dosing› One-a-day formulations (incl. patches)› Match to ADLs (ex. breakfast)

Combination products › Caution: loss of dosing flexibility

Treat multiple conditions with one agent› Caution: commonly 2 agents are safer

d/c extraneous or unnecessary medications

Focus on shared decision making Discuss purposes and side effects of

medications Use the teach-back method Employ verbal and written instructions Give contact information for further

questions

REALM Assessment› http://www.adultmeducation.com/

downloads/REALMR_INSTR.pdf

“As Needed for Water Retention” “Take two every day”

Presentation of the advantages and disadvantages of each medication in a way that is understandable to your patient

Discuss # of missed doses at each visit, non-punitively

Telephone counselling

Empathy, supporting self-efficacy, avoiding argumentation, rolling with resistance, and developing discrepancy

PSAPs VII; Book 8. Motivational Interviewing. Kavookjian J.

Empower patients to self-manageAsk about specific needs, fears, and concernsIdentify perceived barriers (ex. financial)Ensure knowledge of the actual risks of missing medications

Confirm your patient’s message and paraphrase it

Provide empathy and give feedback Involve your patient in decision making Use plain language and confirm

understanding

Take the time to overcome cultural barriers

Tailor education to the appropriate level of complexity for your patient’s optimal understanding

Ask direct questions and ask them often› Every visit

Identify adherence barriers Recognize lack of perceived benefit

30 day fills on Jan 1st, Feb 7th, Mar 18th, Apr 26th, & June 1st 5 fills * 30d each = 150 days supplyJan 1st – Jun 1st = 151 days + 30 days supply = 181 days150/181 = 83% MPR

Wallet cards – medication lists Pill containers and counting Blister packs Pre-packed kits (ex. Medrol) Textured covers with vision impairment Alarms

› On the bottle› Via email

Team based care!

Consider Long-Acting Injectable Antipsychotics

Engage the patient in the treatment decision when able, particularly regarding AEs

Ask the pharmacist to partner with the treatment team to alert of non-timely filling

Depressed patients are 3x more likely to be non-adherent with medical treatment regimens (non psychotropic)

DiMatteo MR, Lepper HS, Croghan TW. Arch Int Med. 2000;160(14):2101.

Polypharmacy is prevalent, particularly in those 65+

Polypharmacy increases morbidity, mortality, & healthcare costs, and decreases quality of life

Perform ongoing medication assessment with tools, like STEPS, to avoid polypharmacy

Use scores, scales, and lists to optimize medication regimens, avoid unnecessary medications, and/or reduce medication burden

To improve medication adherence in polypharmacy, simplify the medication regimen and have ongoing dialogue with your patient about risks and benefits of each drug being used

Stephanie Nichols, Pharm.D., BCPS, BCPPAssociate Professor, Husson University School of PharmacyClinical Psychiatric Pharmacist, Maine Medical CenterNicholsS@Husson.edu

Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20.