Post on 04-Jan-2016
transcript
When to Spare Some Pharmaceutical Care
Jovino Hernandez PharmDClinical Manager
Winter Haven Hospital Pharmacy Services
Goals
Recognize the incidence of polypharmacyIdentify The Risk Associated with
PolypharmacyClassify Agents that Pose the Most Risk
to the Elderly PopulationDevelop Strategies to Decrease
Polypharmacy
Introduction
All drugs can be considered “poisons”The more we ingest, the more apt we are
to have issues Clinical guidelines often call for multiple
medicationsAppropriate medication use beneficial to
patientsChallenge is not to tip the scale toward
adverse events
What is Polypharmacy?
Usually described numerically as five or more prescribed medications at any time
European Project AgeD in Home Care (ADHOC) uses 9 or more medications
orAdministration of more medications than
clinically indicated
Our Aging Population
Chronic Diseases are on the riseMultiple Medications are often used to
treat chronic illnessSharp rise in aging population300% Rise in elderly disabled in North
America by 2050Average North American over the age of
60 years has 2.2 chronic diseases
Our Aging Population
Statistics
Statistics
Statistics
Average elderly patient in community consumes 4 medications daily
Average elderly patient in a nursing home consumes 7 medications on average
Risk Factors
Advanced Age 13% of US population Account for 33% of prescription and 40% on nonprescription use
Female 57% of women greater than 65 years take at least 5 medications 12% take at least 10
Low Education Level Multiple Morbidities
Average adult over 60 years has 2.2 chronic conditions Often based off of evidence based medicine Core Measures
Depression Multiple Prescribers Frailty
Risk Factors (Prescriber)
Practice EnvironmentLow number of listed patientsHigh WorkloadLow rate of admission to hospitalHigh practice prescribing rateHigh average number of prescribed
medicationsLower prevalence in female prescribersNo association with age or duration of practice
Risk Factors (Prescriber)
Medical GuidelinesIntended to support physicians in their drug
choiceUsually focus on one disease stateTend generate more drug therapy especially
when compoundedExamples: CHF, AMI, COPD
Risk Factors (Prescriber)
Prescribing HabitsDominate perception that diseases should be
treated with drugsA visit to a provider should end with a
prescriptionCan lead to a medical cascade of prescribing
Risk Factors (Prescriber)
Physician BehaviorFailure to make a proper medical reviewPoor communication amongst prescribersMistrust of guidelines that decrease
medications use (Antibiotics)
Risk Factors (Patient to Prescriber)
Good interaction essentialReviews of entire medication list with
provider is essentialPersonnel continuity
Multiple providers and pharmacies increase the risk of polypharmacy
Risk
Polypharmacy Associated WithPoor AdherenceInappropriate PrescribingAdverse Drug ReactionsDrug InteractionsGeriatric SyndromesMorbidity/Mortality
Poor Adherence
Nonfulfillment Prescribed but never filled
NonpersistencePatients decides to stop taking without being
advised be health professionalNonconforming
Incorrect DosingSkipping DosesIncorrect times
Inappropriate Prescribing
The use of medications that introduce a greater risk of adverse drug-related events where a safer, as-effective, alternative therapy is available to treat the same condition.
Includes Use of medicines at a higher frequency Longer then clinically necessaryDrug-Drug InteractionsUnderuse of clinically relevant medications
Adverse Reactions
An unfavorable medical event related to medication misuse or
Noxious or unintended response t medication despite appropriate drug dosage or prophylaxis, diagnosis or therapy of medical conditions
Adverse Reactions
4.3 million ADR related health care visits in 2005
Occur in up to 35% of elderly patients in outpatient setting
Account for 10% of ER visits
Adverse Reactions
Higher amount of meds, higher rate of ADRS2 Meds 13%5 Meds 58%7 or more Meds 82%
Adverse Reactions
Most Common ClassesCardiovascularDiureticsAnticoagulantsNSAIDsAntibioticsHypoglycemic
Drug Interactions
Elderly at risk ComorbiditiesNutritional Status
Number of drug interactions increase as number of morbidities and medications increase
Often more medications are added to treat these issues that further complicate problems
Geriatric Syndromes
Cognitive ImpairmentsMedications implicated in up to 39% of casesFour or more medications added the day before
a delirium episode is a risk factorFinnish Study on Cognitive Impairment
No Polypharmacy – 22% riskPolypharmacy – 33% RiskExcessive Polypharmacy – 54% Risk
Geriatric Syndromes
Cognitive Impairments (cont)Delerium
OpiodsBenzodiazepinesAnticholinergics
DementiaBenzodiazepineAnticonvulsantsAnticholinergicsTricyclic Antidepressants
Geriatric Syndromes
FallsIncrease morbidity and mortalityCardiovascular, Psychotropic
Urinary IncontinenceDiureticsPsychotropics OpioidsSedatives
Geriatric Syndromes
NutritionAssociated with poorer nutritional statusDecreased intake of soluble and nonsoluble
fiber, fat soluble vitamins, B vitamins and minerals
Increased intake of cholesterol, glucose and sodium
Medications (Beers)
Updated in 2012Goal
The goal of the 2012 AGS Beers Criteria is to improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs)Improving selection of drugsEvaluating patterns of drug use within populationEducating on proper drug useEvaluating health-outcome, quality care, cost, and use
data
Medications (Beers)
Three CategoriesPotentially inappropriate medications and
classes to avoid in older patientspotentially inappropriate medications and
classes to avoid in older adults with certain diseases and syndromes
medications to be used with caution inolder adults
Beers Criteria for Potentially Inappropriate Use in Older Adults
Medication/Class Rationale
Anticholinergics(diphenhydramine, hydroxyzine, promethazine Clearance reduced, confusion, dry mouth, constipation. Diphenhydramine ok for acute allergic reaction
Alpha1 blockers (doxazosin, prazosin, terazosin) High risk of orthostatichypotension, alternative agents have superior risk/benefit
profile
Antiarrhythmic drugs (Class Ia, Ic,III) (amiodarone, dronaderone, sotalol)
Rate control yields better balance of benefits than rhythm for most older pts
Tricyclic Antidepressants (TCAs) (amitriptyline, doxepin >6mg/d, imipramine
Sedation, orthostatic hypotension
Antipsychotics, first (conventional)and second (atypical) generation (haloperidol, aripiprazole, olanzapine, risperidone, ziprasidone)
Increased risk of cerebrovascularaccident (stroke) and mortality inpersons with dementia
Benzodiazepines (alprazolam, lorazepam, temazepam, clorazepate, chlordiazepoxide, diazepam, zolpidem (not quite a benzodiazepine)
Increased sensitivity, delirium, cognitive impairment, falls. May still be appropriate for some in
Beers Criteria for Potentially Inappropriate Use in Older Adults
Medication/Class Rationale
Insulin, Sliding Scale Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting
Megestrol Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults
Glyburide Greater risk of hypoglycemia in older patients
Metoclopramide Avoid, unless for gastroparesis
Meperidine Not an effective oral analgesic in dosages commonly used; may cause neurotoxicity; safer alternatives available
Indomethacin, Ketorolac Increase risk of GI bleeding and PUD
Carisoprodol, Cyclobenzaprine Poorly tolerated, sedation, questionable efficacy
Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome Interactions That May Exacerbate the Disease or Syndrome
Disease or Syndrome Drug Rationale
Heart Failure NSAIDs, COX-2 Inhibitors, Diltiazam, Verapramil, Pioglitazone, Rosiglitazone, Dronedarone
Potential to promote fluid retention and exacerbate heartfailure
Syncope Doxazosin, Prazosin, Terazosin Increases risk oforthostatic hypotension
Chronic seizuresor epilepsy
Bupropion, Olanzapine, Tramadol Lowers seizure threshold
Delirium TCAs, Anticholinergics, Benzodiazepines, corticosteroids, meperidine,
Avoid in patients with or at high risk for delirium
Dementia andcognitiveimpairment
Anticholinergis, Benzodiazipines, Zolpidem, Antipsychotics
CNS effects. Anitpsychotics -Increase in stroke and mortality in persons with dementia
History of falls orfractures
Anticonvulsants,AntipsychoticsBenzodiazepines, Zolpidem,TCAs and SSRIs
Ability to produce ataxia, impaired psychomotor function,syncope, and additional falls;
Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome Interactions That May Exacerbate the Disease or Syndrome
Disease or Syndrome
Drug Rationale
Parkinson’sdisease
All antipsychotics except for Quetiapine and Clozapine)Antiemetics-MetoclopramideProchlorperazine, Promethazine
Dopamine receptor antagonists with potential to worsenparkinsonian symptoms.
History of gastricor duodenal ulcers
Aspirin (>325 mg/d) Non–COX-2 selective NSAIDs May exacerbate existing
May exacerbate existing ulcers or cause new or additional ulcers
Urinary incontinence(all types) in women
Estrogen oral and transdermal(excludes intravaginal estrogen)
Aggravation of incontinence
Lower urinarytract symptoms,benign prostatichyperplasia
Ipratropium, Tiotropium, Anticholinergics (except antimuscarinics for urinary incontinence)
May decrease urinaryflow and causeurinary retention
Stress or mixedurinary incontinence
Doxazosin, Prazosin, Terazosin
Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome Interactions That May Exacerbate the Disease or Syndrome
Drug Rationale Recommendation
Dabigatran Greater risk of bleeding than with warfarin in adults 75 or greater; lack o evidence for efficacy and safety inindividuals with CrCl < 30 mL/min
Use with caution in adultsaged _75 or if CrCl < 30 mL/min
Antipsychotics, Carbamazepine, Mirtazapine, SSRIs, TCAs
May exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia; need to monitor sodium level closely when starting or changing dosages in older adults due to increased risk
Use with caution
Preventions
BarriersClinician uncomfortable with changing or
discontinuingParticularly medication prescribed by another
clinician
Little evidence based support on discontinuing medications
Patients psychologically or physical dependant on medication
Discontinuing medication perceived as inadequate care
Prevention
Barriers (cont)Potential harms such as adverse drug
withdrawal events (ADWEs)Clinically significant symptoms or signs likely caused
by medication cessationCardiovascular and CNS classes most common
Prevention
ConsiderationsDuration of each medicationIs there still an indication for each medicationAre indications consistent with current
guidelinesAdherence
If patient well without taking, pointless to continue prescribing
Prevention
Prescribing cascadeDiscontinuing medication may reveal adverse
effects of other therapies
Very little evidence to guide withdrawal process for polypharmacyA gradual tapering is often recommended
Prevention
Clinical Controlled TrialsMedication Reviews by pharmacistPrescriber Education ProgramsAcademic detailingComprehensive geriatric assessmentsMultidisciplinary interventions engaging
prescribers and pharmacists
Prevention
Nurses RoleInformationInstructionOrganization
Prevention
Information –Discuss with patientsKeep an accurate list of medicationsKeep complete list of medical providers and
contact informationPost the name and telephone number of local
pharmacy
Prevention
Instruction: Teach patients aboutEach medication, including name, appearance,
purpose and effectsPotential adverse effects and interactions of
each medicationImportance of contacting healthcare provider
with concerns and questionsPotential drug –related problems that warrant
emergency care
Prevention
Instructions (continued)Importance of taking medications exactly as
directedImportance of using only one pharmacy to
obtain drugs
Prevention
Organization: To help manage drugsAvoid sharing medicationsStore medication in secure dry area away from
sunlightRefrigerate if necessaryDispose of old medications properly
Prevention
No single approach extensively studiedPrescribing and impact on outcomes
inconsitent throughout studiesBest approach is probable a combined
approachPatient needs to be involved in the
process
Where Are We Now?
No charges over C. diff outbreak
No-one is to face charges in
connection with an outbreak of
Clostridium difficile which left 90
people dead.
C. difficile Outbreak Causes
Concern At Local Hospital
Tuesday June 3, 2008
CityNews.Ca Staff
Quebec 2004
March 2003 a rise of severe CDAD in Montreal and regions in Quebec1
12 Hospitals studied over 6 months in 2004
1719 cases reviewed
Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associate diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9
Quebec 2004Age
Age (yrs)Age (yrs) CasesCases No of Cases No of Cases per 1000 per 1000 admissionsadmissions
% Attributable % Attributable 30-Day 30-Day Mortality RateMortality Rate
<40<40 7676 3.53.5 2.62.6
41-5041-50 8585 11.211.2 1.21.2
51-6051-60 181181 20.020.0 3.23.2
61-7061-70 272272 24.424.4 5.15.1
71-8071-80 523523 38.338.3 6.26.2
81-9081-90 458458 54.454.4 10.210.2
>90>90 114114 74.474.4 14.014.0Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9
Quebec 2004Antibiotics
AntibioticAntibiotic Odds RatioOdds RatioAny CephalosporinAny Cephalosporin 3.83.8
11stst Generation Generation 2.42.4
22ndnd Generation Generation 6.06.0
33rdrd Generation Generation 3.03.0
Any FluoroquinoloneAny Fluoroquinolone 3.93.9
CiprofloxacinCiprofloxacin 3.13.1
Gatifloxacin/MoxifloxacinGatifloxacin/Moxifloxacin 3.43.4
LevofloxacinLevofloxacin 0.60.6
ClindamycinClindamycin 1.61.6
MacrolidesMacrolides 1.31.3
Penicillin w/Penicillin w/ββ-Lactamase Inh-Lactamase Inh 1.21.2
CarbapenemsCarbapenems 1.41.4
Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9
Quebec 2004
Attributed Mortality 6.9%A previous Canadian study 6 years prior had 1.5%
mortality rate1
All hospitals had the similar dominant strain (129 of 157 isolates or 82%)
Among the 38 patients who acquired CDAD in the community, 37% had NAP1/027
Isolates of dominant strain resistant to all quinolones but susceptible to clindamycin
Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9
NAP1/027 Strain
Linked to several outbreaks in Canada, Britain, US, and Netherlands.
Has been around since 1984 Has become fluoroquinolone resistant since then
Can produce 16 times more toxin A and 23 times more toxin B than standard strain
Produces an extreme amount of sporesHigher mortality and colectomies Has in many area become the dominate strain
Possibly due to severe diarrheaAntibiotic trends
Florida
1998-20031
Codes as C. diff on discharge34/100,000 to 70.2/100,000
• Biggest change from 2000-2001 (35.0 to 46.9)
Death among patients coded with C. Diff94.8/1000 to 106.7/1000
• More than 80% of deaths were 75 or older
Authors felt the NAP1/027 was a contributing factor
Sanderson, R A, Bendixsen O, Increasing Clostridium difficile morbidity and mortality, Florida hospitals, 1998-2003, Abstract 2006 Conference on Antimicrobial Resistance
Community-Acquired
Definition controversialMany have been in a health care facility recentlyLocal study showed that 79% of CDAD patients in
hospital acquired if considering 30 day readmission criteria
Young patients without a history of antibiotic use becoming more commonMany have close contact with diarrheal CDAD1
NAP1/027 is out in the community
1Centers for Disease Control and Prevention. Severe Clostridium difficile-associated disease in populations previously at low risk—Four States, 2005. MMWR Morb Mortal Wkly Rep 2005;54:1201-5
Risk Factors(Hospitalized Patients)Increasing Age (excluding infancy)
Younger population is becoming more at riskSeverity of Underlying DiseaseNon-surgical gastrointestinal proceduresPresence of nasograstric tubesAnti-ulcer medicationsICU StayLength of Hospital StayAntibiotics
Length of therapyMultiple Antibiotics
Antibiotics
FluoroquinolonesOriginally considered a low riskReadily available, particularly ciprofloxacinEliminates gram negative and anaerobicFull resistance to the newer NAP1/027 strain
Appropriate use
Use narrower spectrum where possible
Minimize usage of “double coverage” Streamline antibiotics as soon as possible
Minimize the use of agents that are largely excreted in the gut to minimize the selection of resistant gram negatives and destroy gut flora
Minimize use of agents that have significant antianaerobic activity-spare gut anaerobes
Shorten the length of therapy