1. When to Spare Some Pharmaceutical Care
Jovino Hernandez PharmD
Clinical Manager
Winter Haven Hospital Pharmacy Services

2. Goals Recognize the incidence of polypharmacy
Identify The Risk Associated with Polypharmacy
Classify Agents that Pose the Most Risk to the Elderly Population
Develop Strategies to Decrease Polypharmacy

3. 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 medications
Appropriate medication use beneficial to patients
Challenge is not to tip the scale toward adverse events

4. 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 or
Administration of more medications than clinically indicated

5. Our Aging Population Chronic Diseases are on the rise
Multiple Medications are often used to treat chronic illness
Sharp rise in aging population
300% Rise in elderly disabled in North America by 2050
Average North American over the age of 60 years has 2.2 chronic diseases

6. Our Aging Population

7. Statistics

8. Statistics

9. Statistics
Average elderly patient in community consumes 4 medications daily
Average elderly patient in a nursing home consumes 7 medications on average

10. Risk Factors Advanced Age Female Low Education Level
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

11. Risk Factors (Prescriber)
Practice Environment
Low number of listed patients
High Workload
Low rate of admission to hospital
High practice prescribing rate
High average number of prescribed medications
Lower prevalence in female prescribers
No association with age or duration of practice

12. Risk Factors (Prescriber)
Medical Guidelines
Intended to support physicians in their drug choice
Usually focus on one disease state
Tend generate more drug therapy especially when compounded
Examples: CHF, AMI, COPD

13. Risk Factors (Prescriber)
Prescribing Habits
Dominate perception that diseases should be treated with drugs
A visit to a provider should end with a prescription
Can lead to a medical cascade of prescribing

14. Risk Factors (Prescriber)
Physician Behavior
Failure to make a proper medical review
Poor communication amongst prescribers
Mistrust of guidelines that decrease medications use (Antibiotics)

15. Risk Factors (Patient to Prescriber)
Good interaction essential
Reviews of entire medication list with provider is essential
Personnel continuity
Multiple providers and pharmacies increase the risk of polypharmacy

16. Risk Polypharmacy Associated With Poor Adherence
Inappropriate Prescribing
Adverse Drug Reactions
Drug Interactions
Geriatric Syndromes
Morbidity/Mortality

17. Poor Adherence Nonfulfillment Nonpersistence Nonconforming
Prescribed but never filled
Nonpersistence
Patients decides to stop taking without being advised be health professional
Nonconforming
Incorrect Dosing
Skipping Doses
Incorrect times

18. 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 necessary
Drug-Drug Interactions
Underuse of clinically relevant medications

19. 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

20. 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

21. Adverse Reactions Higher amount of meds, higher rate of ADRS
7 or more Meds 82%

22. Adverse Reactions Most Common Classes Cardiovascular Diuretics
Anticoagulants
NSAIDs
Antibiotics
Hypoglycemic

23. Drug Interactions Elderly at risk
Comorbidities
Nutritional 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

24. Geriatric Syndromes Cognitive Impairments
Medications implicated in up to 39% of cases
Four or more medications added the day before a delirium episode is a risk factor
Finnish Study on Cognitive Impairment
No Polypharmacy – 22% risk
Polypharmacy – 33% Risk
Excessive Polypharmacy – 54% Risk

25. Geriatric Syndromes Cognitive Impairments (cont) Delerium Dementia
Opiods
Benzodiazepines
Anticholinergics
Dementia
Benzodiazepine
Anticonvulsants
Tricyclic Antidepressants

26. Geriatric Syndromes Falls Urinary Incontinence
Increase morbidity and mortality
Cardiovascular, Psychotropic
Urinary Incontinence
Diuretics
Psychotropics
Opioids
Sedatives

27. Geriatric Syndromes Nutrition
Associated with poorer nutritional status
Decreased intake of soluble and nonsoluble fiber, fat soluble vitamins, B vitamins and minerals
Increased intake of cholesterol, glucose and sodium

28. Medications (Beers) Updated in 2012 Goal
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 drugs
Evaluating patterns of drug use within population
Educating on proper drug use
Evaluating health-outcome, quality care, cost, and use data

29. Medications (Beers) Three Categories
Potentially inappropriate medications and classes to avoid in older patients
potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes
medications to be used with caution in
older adults

30. 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 orthostatic
hypotension, 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 cerebrovascular
accident (stroke) and mortality in
persons 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

31. Greater risk of hypoglycemia in older patients Metoclopramide
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

32. 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 heart
failure
Syncope
Doxazosin, Prazosin, Terazosin
Increases risk of
orthostatic hypotension
Chronic seizures
or epilepsy
Bupropion, Olanzapine, Tramadol
Lowers seizure threshold
Delirium
TCAs, Anticholinergics, Benzodiazepines, corticosteroids, meperidine,
Avoid in patients with or at high risk for delirium
Dementia and
cognitive
impairment
Anticholinergis, Benzodiazipines, Zolpidem, Antipsychotics
CNS effects. Anitpsychotics -Increase in stroke and mortality in persons with dementia
History of falls or
fractures
Anticonvulsants,Antipsychotics
Benzodiazepines, Zolpidem,
TCAs and SSRIs
Ability to produce ataxia, impaired psychomotor function,
syncope, and additional falls;

33. Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome Interactions That May Exacerbate the Disease or Syndrome
Disease or Syndrome
Drug
Rationale
Parkinson’s
disease
All antipsychotics except for Quetiapine and Clozapine)
Antiemetics-Metoclopramide
Prochlorperazine, Promethazine
Dopamine receptor antagonists with potential to worsen
parkinsonian symptoms.
History of gastric
or 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 urinary
tract symptoms,
benign prostatic
hyperplasia
Ipratropium, Tiotropium, Anticholinergics (except antimuscarinics for urinary incontinence)
May decrease urinary
flow and cause
urinary retention
Stress or mixed
urinary incontinence
Doxazosin, Prazosin, Terazosin

34. 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 in
individuals with CrCl < 30 mL/min
Use with caution in adults
aged _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

35. Preventions
Barriers
Clinician uncomfortable with changing or discontinuing
Particularly 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

36. Prevention Barriers (cont)
Potential harms such as adverse drug withdrawal events (ADWEs)
Clinically significant symptoms or signs likely caused by medication cessation
Cardiovascular and CNS classes most common

37. Prevention Considerations Duration of each medication
Is there still an indication for each medication
Are indications consistent with current guidelines
Adherence
If patient well without taking, pointless to continue prescribing

38. Prevention Prescribing cascade
Discontinuing medication may reveal adverse effects of other therapies
Very little evidence to guide withdrawal process for polypharmacy
A gradual tapering is often recommended

39. Prevention Clinical Controlled Trials Medication Reviews by pharmacist
Prescriber Education Programs
Academic detailing
Comprehensive geriatric assessments
Multidisciplinary interventions engaging prescribers and pharmacists

40. Prevention
Nurses Role
Information
Instruction
Organization

41. Prevention Information –Discuss with patients
Keep an accurate list of medications
Keep complete list of medical providers and contact information
Post the name and telephone number of local pharmacy

42. Prevention Instruction: Teach patients about
Each medication, including name, appearance, purpose and effects
Potential adverse effects and interactions of each medication
Importance of contacting healthcare provider with concerns and questions
Potential drug –related problems that warrant emergency care

43. Prevention Instructions (continued)
Importance of taking medications exactly as directed
Importance of using only one pharmacy to obtain drugs

44. Prevention Organization: To help manage drugs
Avoid sharing medications
Store medication in secure dry area away from sunlight
Refrigerate if necessary
Dispose of old medications properly

45. Prevention No single approach extensively studied
Prescribing and impact on outcomes inconsitent throughout studies
Best approach is probable a combined approach
Patient needs to be involved in the process

47. C. difficile Outbreak Causes Concern At Local Hospital
Where Are We Now?
C. difficile Outbreak Causes Concern At Local Hospital
Tuesday June 3, 2008
CityNews.Ca Staff
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.

48. 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

49. Quebec 2004 Age
Age (yrs)
Cases
No of Cases per 1000 admissions
% Attributable 30-Day Mortality Rate
<40 76
3.5
2.6
41-50 85
11.2
1.2
51-60
181
20.0
3.2
61-70
272
24.4
5.1
71-80
523
38.3
6.2
81-90
458
54.4
10.2
>90
114
74.4
14.0
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

50. Quebec 2004 Antibiotics Antibiotic Odds Ratio Any Cephalosporin 3.8
1st Generation
2.4
2nd Generation
6.0
3rd Generation
3.0
Any Fluoroquinolone
3.9
Ciprofloxacin
3.1
Gatifloxacin/Moxifloxacin
3.4
Levofloxacin
0.6
Clindamycin
1.6
Macrolides
1.3
Penicillin w/β-Lactamase Inh
1.2
Carbapenems
1.4
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

51. 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

52. 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 spores
Higher mortality and colectomies
Has in many area become the dominate strain
Possibly due to severe diarrhea
Antibiotic trends

53. Florida 1998-20031 Codes as C. diff on discharge
34/100,000 to 70.2/100,000
Biggest change from (35.0 to 46.9)
Death among patients coded with C. Diff
94.8/1000 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, , Abstract 2006 Conference on Antimicrobial Resistance

54. Community-Acquired Definition controversial
Many have been in a health care facility recently
Local 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 common
Many 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, MMWR Morb Mortal Wkly Rep 2005;54:1201-5

55. Risk Factors (Hospitalized Patients)
Increasing Age (excluding infancy)
Younger population is becoming more at risk
Severity of Underlying Disease
Non-surgical gastrointestinal procedures
Presence of nasograstric tubes
Anti-ulcer medications
ICU Stay
Length of Hospital Stay
Antibiotics
Length of therapy
Multiple Antibiotics

56. Antibiotics Fluoroquinolones Originally considered a low risk
Readily available, particularly ciprofloxacin
Eliminates gram negative and anaerobic
Full resistance to the newer NAP1/027 strain

57. 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