Presentation on theme: "Ottawa Regional Geriatric Program"— Presentation transcript:
1Ottawa Regional Geriatric Program POLYPHARMACYDr. Bill DalzielChiefOttawa Regional Geriatric Program
2Question 1Approximately how much was spent on prescription drugs in Canada in 2003? (total health care costs approximately $110B)$ 5 B (4.5%)$ 8 B (7.3%)$11 B (10%)$15 B (13.6%)$22 B (20%)
310-15% of hospital admissions of the elderly are due to ADRs: Adverse Drug Reactions.
4Consequences of ADR30% of hospital admissions linked to ADR in US ( Hanlon et al. JAGS 1997)After discharge from TOH, 23% had at least one ADR ( Forster et al. CMAJ 2004)ADR in the older person linked to depression, constipation, falls, immobility, confusion, and hip fractures… (Bootman et al. AIM 1997)
6Question 2What is the biggest reason why the elderly are at such high risk for ADRs (Adverse Drug Reactions)Polysymptomatology breeding polypharmacy.Homeostenosis.Pharmacokinetics. Pharmacodynamics.All those pharmacology lectures in medical school (sic!).Pharmaceutical companies: research and marketing.
7Drugs and The Older Person Statistics 30% of prescription drug use40% of non prescription drug useAverage use of 4.5 medications (community)Average use of 9.1 medications (hospitalized)
8Question 3How much does the creatinine clearance decrease as someone ages from 50 to 80? (even though serum creatinine may not change).5%15%25%35%45%
9Calculation of Creatinine Clearance Cockcroft / Gault EquationCrcl= (140 - AGE) x wt (kgm) x (x .085 for women)Serum CreatinineChanging age from 50 to 80 decreases Crcl by 1/3!
10The 10 Do’s and Don’ts1. Think of every drug prescribed as a clinical trial with N=1.
11The 10 Do’s and Don’ts2. Always think of drugs as the diagnosis of any newsymptom.Drugs - PrescriptionDrugs - OTC/OTFDrugs - AlcoholDrugs - Herbal
12Question 4The elderly (65+) are 12% of the Canadian population; what % of OTC drugs do they consume?10%20%30%40%50%
13Over the Counter Medications in the Elderly The elderly consume 40% of all OTC.Top 5AcetaminophenMultivitaminsASAAluminum HydroxideCough and ColdSeniors perceive as “safe”, usually don’t tell their doctor about use.Toxicity and drug interaction problems.
14The 10 Do’s and Don’ts3. The only rule you learned about the elderly and drugs in medical school, “START LOW GO SLOW” was only ½ correct.
15The 10 Do’s and Don’ts You need to push/titrate the dosage up until: Therapeutic goals are met.Side effects.You have your maximum comfortable dosage.
16Question 5? How many drugs do you need (pharmacopia) to take care of 90% of your elderly patient’s prescription needs?10255075100
18The 10 Do’s and Don’ts4. You only need a small PHARMACOPOEIA.(25)
19The 10 Do’s and Don’ts 5. Regularly review drug regimens and risk reducing drugs regularly.VA Study 74% of selected drugs d/cdsuccessful.(? Why do we worry more about stopping drugs than starting drugs?)
20The 10 Do’s and Don’ts 6. Avoid the bandwagon of new drugs unless researched in the elderly or extensively used elsewhere. Ask your drug reps about trials and clinical experience involving elderly subjects.
21The 10 Do’s and Don’ts 7. KNOWLEDGE is YOUR RESPONSIBILITY. Trials in the elderly.Absolute/Relative CI.Major and minor adverse effects.Drug/drug and drug/disease interactions.Starting/usual/maximum dosages.Cost.
22“How do you extrapolate research trials The 10 Do’s and Don’ts8. IF YOU’RE GOING TO PRACTISEPOLYPHARMACY AT LEAST MAKE ITEVIDENCE BASED POLYPHARMACY.OR“How do you extrapolate research trialsto 85 years old patients?
23Question 6In the EBM (evidence based medicine) world, usual RCTs do not include patients over 75. How can you extrapolate from these results to your 85 year old patients in terms of RRR (relative risk reduction) and ARR (absolute risk reduction). Generally with increasing age above 65…RRR decreases, ARR decreases (NNT increases)RRR decreases, ARR stays the same (NNT stays the same)RRR stays the same, ARR increases (NNT decreases)RRR stays the same, ARR stays the same (NNT stays the same)RRR increases, ARR increases (NNT decreases)
24In RCTs with Increasing age: Relative Risk Reduction (RRR) generally remains the sameAbsolute risk reduction (ARR) increases NNT decreases
25Canada (Annual Deaths related to ADR) Question 7What is your chance of having a patient in which an adverse drug significantly contributed to mortality? Which is true?Canada (Annual Deaths related to ADR)Physician Risk1. 1,0001 patient per 60 years2. 5,0001 patient per 12 years3. 10,0001 patient per 6 years4. 30,0001 patient per 2 years,0003.3 patients per year
26The 10 Do’s and Don’ts 9. The sword is DOUBLE EDGED! Canadian Estimate: 200,000 serious ADRs/year10,000 deaths/yearBut also under-medication.
27Question 8What % of patients on antihypertensives are significantly non-compliant within 1 year of initiating therapy?10%20%33%50%75%
28The 10 Do’s and Don’ts 10. Noncompliance is a HUGE ISSUE (75% antihypertensives at 1 year).KISSNon-childproof containers.Clear, large labels.Patient explanation/education.Pharmacists -- total pharmaceutical care.
29The Top 10 Drugs to Use Less Conventional NSAIDS.GI bleeds use without prodromal c/oNa/H2O retention CR. K BP
30The Top 10 Drugs to Use Less Benzodiazepines.Falls, falls, fallsFirst time anxiety in the elderly is not a benzodiazepine deficiency syndrome.Alternatives for insomnia.R/O causesNon pharmacologicTrazadone (25-50 mgm)
31Question 9What is the rate of tardive dyskinesia within 3 years of starting therapy with conventional neuroleptics in elderly patients (65 +).5%25%40%70%100%
32The Top 10 Drugs to Use Less Conventional Neuroleptics.70% Tardive Dyskinesia (3 year)EPSOversedation18% efficacy above placebo40 vs 58%
33The Top 10 Drugs to Use Less Beta Blockers.Less effective than HCTZ in BPUseful post MIVery useful in CHF(NY II – IV ( EF)(Start lower, go slower).
34The Top 10 Drugs to Use Less GlyburideMore hypoglycemia.16.6 / 1000 patient years
35Question 10How much $ is spent in Canada per year on colace a drug with ABSOLUTELY NO laxative properties?$1 million$5 million$25 million$50 million$150 million
36The Top 10 Drugs to Use Less Colace/Irritant Laxatives.Colace is not a laxative but we spend in Canada $50M/yearlySennosides ok short term but risk of cathartic colon long term.
37The Top 10 Drugs to Use Less Elavil/AmitriptylineVery anticholinergicOther alternatives in chronic pain – nortryptaline and desipramine.SSRIs
38The Top 10 Drugs to Use Less Anticholinergic Drugs.Central = delirium/dementiaPeripheral = retention, constipation.
39The Top 10 Drugs to Use Less Talwin, Demerol, p.o.Ineffective, toxic.
40The Top 10 Drugs to Use Less Serc/gravol.Ineffective, toxic.
41The Top 10 Drugs to Use More COX 2 NSAIDS.Only better than conventional NSAIDs in major GI events.Cardiovascular toxicity concern.
42The Top 10 Drugs to Use More 2. Drugs to treat depression:SSRI (Celexa), Effexor XR and TCA with lowanticholinergic properties(desipramine,’nortryptaline).> 2 year maintenanceSSRIs have side effects:GIParkinson’sAnxietySIADHSeizuresDiscontinuation syndrome.
43The Top 10 Drugs to Use More 3. Drugs to treat dementia: ACHEI(Aricept, Exelon, Reminyl).Standard of care = trial.¼ super responder.½ mild responder.¼ non responder (switch).(9 weeks of holidays for caregiver)NNT < 10
44Question 11With respect to Coumadin for atrial fibrillation and the concerns about falls in the elderly, how many falls per year do you need to = the risk of not anticoagulating?2510100300
45The Top 10 Drugs to Use More Coumadin (for atrial fibrillation).68% RRR vs 21% ASA.INR must be over 2.0 (2.5).295 falls/year.
46The Top 10 Drugs to Use More 5. Drugs to treat hypertension, especially systolic:(diuretics, CCB/ACEI)/ARB.CVA, CVS, dementiaSystolic 165 = diastolic 105Goal = 140/90 (add ASA)Small doses triple Rx
47The Top 10 Drugs to Use More 6. Drugs to treat osteoporosis:(calcium, vitamin D, bisphosphonates), raloxifene.2002 CPG CMAJ Nov. 12/02All 65 DXA screeningVit D 800 IU/Ca 1500 mgm/exerciseFosamax/Actonel/didrocalhPTH (to come)
48The Top 10 Drugs to Use More Drugs to treat diabetes.Metformin2nd generation sulfonylureaGlucosidase inhibitorsThiazolidinediones (glitazones)
49Question 12What % of patients cannot metabolize codeine (prodrug with no analgesic effect) into the active metabolite morphine?0.7%1%2.5%5%10%
50The Top 10 Drugs to Use More Anaglesics (regular dosing, not PRN).10% can’t metabolize codeineNew acetaminophen limit 3gm/dSR strong opioids/duragesic(AGS Guidelines, JAGS June , Supplement)Nocioceptive: TCA (yes) SSRI (no)Neuropathic: TCA (better than SSRI)
51The Top 10 Drugs to Use More Statins.A huge lost opportunity!CVS m & m reduction: 1o/2oDementia(www.cvtoolbox.com)