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POLYPHARMACY Wendolyn Gozansky, MD, MPH Associate Professor Division of Geriatric Medicine University of Colorado Denver THE AMERICAN GERIATRICS SOCIETY.

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Presentation on theme: "POLYPHARMACY Wendolyn Gozansky, MD, MPH Associate Professor Division of Geriatric Medicine University of Colorado Denver THE AMERICAN GERIATRICS SOCIETY."— Presentation transcript:

1 POLYPHARMACY Wendolyn Gozansky, MD, MPH Associate Professor Division of Geriatric Medicine University of Colorado Denver THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. AGS

2 CONTENTS Drugs and the elderly Pharmacodynamic and pharmacokinetic changes with aging Drug knowledge and compliance Prudent prescribing Slide 2

3 DRUG USE IN THE ELDERLY 12% of the population is aged 65+ Slide 3

4 DRUG USE IN THE ELDERLY 12% of the population is aged % of all prescription drug use is among those aged 65+ Slide 4

5 DRUG USE IN THE ELDERLY 12% of the population is age % of all prescription drug use is among those aged % of all OTC drug use is among those aged 65+ Slide 5

6 ADVERSE DRUG REACTIONS (ADRs) 106,000 deaths in 1994 Slide 6

7 ADVERSE DRUG REACTIONS (ADRs) 106,000 deaths in 1994 $177 billion in 2000 Slide 7

8 ADVERSE DRUG REACTIONS (ADRs) 106,000 deaths in 1994 $177 billion in 2000 For every $1 spent on drugs, $1 spent on ADRs Slide 8

9 ADVERSE DRUG REACTIONS (ADRs) 106,000 deaths in 1994 $177 billion in 2000 For every $1 spent on drugs, $1 spent on ADRs 95% of ADRs considered to be predictable Slide 9

10 ADVERSE DRUG REACTIONS (ADRs) 106,000 deaths in 1994 $177 billion in 2000 For every $1 spent on drugs, $1 spent on ADRs 95% of ADRs considered to be predictable 7-fold increased risk in the elderly Related to polypharmacy Changes in pharmacodynamics/pharmacokinetics Drug-disease interactions Slide 10

11 EXPONENTIAL RELATION BETWEEN POLYPHARMACY AND ADRs Nolan L. JAGS. 1988;36(2): Slide 11

12 CONTENTS Drugs and the elderly Pharmacodynamic and pharmacokinetic changes with aging Drug knowledge and compliance Prudent prescribing Slide 12

13 PHARMACODYNAMICS Response that occurs when a drug interacts at its receptor Slide 13

14 PHARMACODYNAMIC CHANGES WITH AGING Increased response (eg, opiates) Slide 14

15 PHARMACODYNAMIC CHANGES WITH AGING Increased response (eg, opiates) Decreased response (eg, beta-agonists) Slide 15

16 PHARMACOKINETICS Drug concentration at the site of action Slide 16

17 PHARMACOKINETICS Drug concentration at the site of action 4 determinants: Absorption Distribution Metabolism Elimination Slide 17

18 PK CHANGES WITH AGING: ABSORPTION gastric pH gastric emptying splanchnic blood flow intestinal motility Minimal clinical importance Slide 18

19 PK CHANGES WITH AGING: DISTRIBUTION fat mass muscle mass total body water albumin (binds acidic drugs) alpha-1 glycoprotein (binds basic drugs) Clinically important Slide 19

20 20-year-old woman Rosenberg, I. J Nutr (5): S. Published with permission.

21 64-year-old woman 20-year-old woman Rosenberg, I. J Nutr (5): S. Published with permission.

22 64-year-old woman 20-year-old woman Rosenberg, I. J Nutr (5): S. Published with permission.

23 64-year-old woman 20-year-old woman Rosenberg, I. J Nutr (5): S. Published with permission.

24 hepatic mass hepatic blood flow first-pass metabolism Clinically important: Longer half-life of drugs undergoing phase I metabolism (eg, diazepam vs lorazepam) PK CHANGES WITH AGING: METABOLISM Slide 24

25 renal mass renal blood flow glomerular filtration rate Most clinically important concentration of drugs dependent on renal clearance Serum creatinine alone does not provide adequate information to guide dosing PK CHANGES WITH AGING: ELIMINATION Slide 25

26 PHARMACOKINETIC CHANGES WITH AGING What is the best formula for estimating GFR in older adults? Cockcroft-Gault (CG) Modification of Diet in Renal Disease (MDRD) Slide 26

27 CG VERSUS MDRD Slide 27

28 CG VERSUS MDRD Slide 28

29 BIOLOGY OF THE PATIENT Limited functional reserve Slide 29

30 BIOLOGY OF THE PATIENT Disease Compensatory severitymechanisms SymptomaticAsymptomatic Resnick N.M, Marcantonio E.R. The Lancet. 1992;350(9085): Published with permission. Slide 30

31 BIOLOGY OF THE PATIENT Limited functional reserve Drug-disease interactions Slide 31

32 CONTENTS Drugs and the elderly Pharmacodynamic & pharmacokinetic changes with aging Drug knowledge and compliance Prudent prescribing Slide 32

33 DO YOU KNOW WHATS IN YOUR PATIENTS MEDICINE CABINET? ~20% of drugs found on home inventory were not revealed by physician interview Most frequently unreported class of drugs? Slide 33

34 Slide 34

35 DO YOU KNOW WHATS IN YOUR PATIENTS MEDICINE CABINET? ~20% of drugs found on home inventory were not revealed by physician interview Most frequently unreported class of drugs? BENZODIAZEPINES!!! Slide 35

36 ALTERED COMPLIANCE Under-utilization Over-utilization Enforced compliance Slide 36

37 RELATION BETWEEN POLYPHARMACY AND NUMBER OF PRESCRIBERS Slide 37

38 RELATION BETWEEN POLYPHARMACY AND COMPLIANCE Slide 38

39 METHODS TO IMPROVE COMPLIANCE # of drugs, prescribers, and pharmacies Once-daily or twice-daily dosing Pill boxes Medication reminder charts frequency of clinic visits Slide 39

40 CONTENTS Drugs and the elderly Pharmacodynamic & pharmacokinetic changes with aging Drug knowledge and compliance Prudent prescribing Slide 40

41 AVOID THE PRESCRIBING CASCADE Drug 1 BMJ. 1997;315: Slide 41

42 AVOID THE PRESCRIBING CASCADE Drug 1 Adverse effect misinterpreted as new medical condition Rochon, P. BMJ. 1997;315: Published with permission. Slide 42

43 AVOID THE PRESCRIBING CASCADE Drug 1 Adverse effect misinterpreted as new medical condition Drug 2 Slide 43 Rochon, P. BMJ. 1997;315: Published with permission.

44 AVOID THE PRESCRIBING CASCADE HCTZ – Allopurinol NSAIDs – Antihypertensives Metoclopramide – Carbidopa/levodopa Cholinesterase inhibitors – Tolterodine Slide 44

45 BEWARE OF DRUG-DRUG INTERACTIONS (DDIs) 100% chance of DDIs with 8 drugs Slide 45

46 BEWARE OF DRUG-DRUG INTERACTIONS (DDIs) 100% chance of DDIs with 8 drugs Nearly 50% of community-dwelling geriatric patients had at least one DDI Slide 46

47 BEWARE OF DRUG-DRUG INTERACTIONS (DDIs) 100% chance of DDIs with 8 drugs Nearly 50% of community-dwelling geriatric patients had at least one DDI DDIs can result in ADRs or suboptimal dosing Slide 47

48 PRUDENT PRESCRIBING PRINCIPLES Know your patients and their drug cabinets Slide 48

49 PRUDENT PRESCRIBING PRINCIPLES Know your patients and their drug cabinets Educate yourself and your patients Slide 49

50 PRUDENT PRESCRIBING PRINCIPLES Know your patients and their drug cabinets Educate yourself and your patients Understand biases in clinical trials Slide 50

51 PRUDENT PRESCRIBING PRINCIPLES Know your patients and their drug cabinets Educate yourself and your patients Understand biases in clinical trials Ask about compliance Slide 51

52 PRUDENT PRESCRIBING PRINCIPLES Know your patients and their drug cabinets Educate yourself and your patients Understand biases in clinical trials Ask about compliance Always include ADRs in the differential diagnosis of a new problem Slide 52

53 PRUDENT PRESCRIBING PRINCIPLES Know your patients and their drug cabinets Educate yourself and your patients Understand biases in clinical trials Ask about compliance Always include ADRs in the differential diagnosis of a new problem Try non-pharmacologic strategies Slide 53

54 PRUDENT PRESCRIBING PRINCIPLES Know your patients and their drug cabinets Educate yourself and your patients Understand biases in clinical trials Ask about compliance Always include ADRs in the differential diagnosis of a new problem Try non-pharmacologic strategies Offer drug therapy when indicated Slide 54

55 Which of the following is an age- related change that causes clinically significant alterations in drug pharmacokinetics? A.Decreased fat mass B.Increased gastric pH C.Decreased glomerular filtration rate D.Increased total body water :10 Fick D.M, et al. Arch Intern Med. 2003;163(22) :

56 Which of the following does not contribute to adverse drug reactions (ADRs) in the elderly? A.All prescriptions written by one provider B.Comorbid illness C.Hospitalization D.Increasing numbers of medications :10 Fick D.M, et al. Arch Intern Med. 2003;163(22) :

57 Which of the following is associated with improved medication compliance? A.Increasing numbers of medications B.Clinic visit in the previous 48 hours C.TID dosing D.Drug side effects E.Expensive medications :10 Fick D.M, et al. Arch Intern Med. 2003;163(22) :

58 Which of the following is a principle of prudent prescribing? A.Only inquire about prescribed medications B.Ask the patient, What could possibly be so hard about taking pills every day? C.Do not begin treatment without a diagnosis D.Use drugs before a trial of non-pharmacologic therapy :10 Fick D.M, et al. Arch Intern Med. 2003;163(22) :

59 Which of the following effects of aging contributes to an increased risk of ADRs related to benzodiazepine use? A.Increased body fat mass causing a greater volume of distribution and decreasing drug half-life B.Increased hepatic volume resulting in increased production of active metabolites C.Decreased renal function causing delayed renal excretion :10 Fick D.M, et al. Arch Intern Med. 2003;163(22) :

60 Patients who think they are taking too many medications report lower quality of life than patients who think they are taking the right number of medications. 1.True 2.False :10 Fick D.M, et al. Arch Intern Med. 2003;163(22) :

61 A patient with a serum creatinine of 0.5 mg/dL (within the normal range) will also have a normal creatinine clearance 1.True 2.False :10 Fick D.M, et al. Arch Intern Med. 2003;163(22) :

62 Older adults uniformly exhibit exaggerated pharmacodynamic responses compared with younger adults. 1.True 2.False :10 Fick D.M, et al. Arch Intern Med. 2003;163(22) :

63 Which of the following drugs is/are listed as high-severity potentially inappropriate medications for patients aged 65+? A.Amiodarone (Cordarone) B.Amitriptyline (Elavil) C.Cyclobenzaprine (Flexeril) D.Diazepam (Valium) E.Diphenhydramine (Benadryl) F.Indomethacin (Indocin) G.Ketorolac (Toradol) H.Nitrofurantoin (Macrodantin) I.All of the above :10 Fick D.M, et al. Arch Intern Med. 2003;163(22) :

64 Mark H. Beers, MD Data from "Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: Results of a US Consensus Panel of Experts." Donna M. Fick, PhD, RN, et al. Arch Intern Med. 2003;163(22) :

65 Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics THANK YOU FOR YOUR TIME! linkedin.com/company/american-geriatrics- society Slide 65


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