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Medication Use and Safety in the Elderly
Amy N. Thompson, PharmD, BCPS ACOVE 5 Medical University of South Carolina
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Objectives Understand the physiologic changes associated with aging
Recognize potentially dangerous medications for the elderly Identify risk factors for adverse drug events in the elderly Identify proper monitoring parameters for high risk medications in the elderly
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Challenges of Prescribing for Older Adults
Multiple medical conditions Multiple prescribers Adherence and cost Lack of evidence Supplements, herbals and over-the-counter medications Different metabolisms and distribution
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Physiologic Changes Less body water more body fat Less muscle mass
Decreased hepatic metabolism and renal excretion Decreased responsiveness and sensitivity of the baroreceptor reflex
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Distribution Decreased body water Increased body fat
Decreased volume of distribution Higher concentration of water soluble agents Increased body fat Increased volume of distribution Increased half-life of fat soluble agents Decreased serum proteins Increased concentration of agents that are highly protein bound
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Metabolism Slowed phase I metabolism Unchanged phase II metabolism
Oxidation, reduction, dealkylation Unchanged phase II metabolism Conjugation, acetylation, methylation
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Excretion Reduced kidney clearance
30-40% fall in functioning glomeruli by 80 1% (at age 20) ->30% sclerotic glomeruli Serum creatinine not accurate predictor of renal function due to decreased muscle mass Creatinine secretion reduced ~40%
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Pharmacodynamics Alterations are complex and poorly studied
Generally the elderly are more sensitive to drug effects Anticholinergics Benzodiazepines Homeostasis is more effected by drugs Postural BP EPS Cognition
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Therapeutic Response Toxic Response Therapeutic Window Age
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Medication Use People over the age of 65 consume 30% of all prescriptions in the US and 40% of all over-the-counter medications While they only represent 15% of the US population Clinical trials Elderly frequently not included due to unpredictable drug metabolism and effects
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Diagnosed today with AFib
GF is a 68 y/o AAF PMH: Type 2 Diabetes, HTN, GERD, HLP Medications: Metformin, glipizide, and hydrochlorothiazide, simvastatin Diagnosed today with AFib Started on warfarin 5 mg daily Diltiazem 240 mg daily
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One week later: What is going on?
GF presents to the ER with bilateral LE edema Given a prescription for Lasix 20 mg daily What is going on?
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Medication Safety Think about the medication regimen before making a new diagnosis Consider ADE as etiology of new s/sx Consider reducing dose or stopping medications before treating a ADE with another medication
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Risk Factors for Adverse Drug Events
>6 chronic disease states >12 doses/day >9 Medications Low BMI (<22 kg/m2) Creatinine clearance <50 mL/min Female
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Adverse Drug Events Linked to preventable problems in the elderly, such as: Depression Constipation Falls Immobility Confusion Hip fractures Arch Intern Med.2003;163:
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Avoiding Potentially Dangerous Drugs: Beers Criteria
Consensus-based list of potentially inappropriate medications for older adults Published 1991; revised in 1997, 2002, 2012 Criteria covered 2 types of statements: Medications that should generally be avoided because they are either ineffective or they pose a high risk Medications that should not be used in older persons known to have specific medical conditions J Am Geriatr Soc 2012; 60(4):
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Beers Criteria: Anticholinergic Agents
Drug classes Tricyclic antidepressants Antihistamines Antispasmodics and muscle relaxants Adverse events Urinary incontinence Constipation Confusion, delirium, behavior changes Exacerbation of dementia
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Beers Criteria: Benzodiazepines
Avoid entirely if at all possible Challenging to stop for patients with long-term use Long-acting Prolonged half-life in older adults (days) Sedation, cognitive impairment, depression Increased risk of falls and fractures Short-acting Increased sensitivity in older adults If necessary, use lower doses
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Beers Criteria: Pain Medications
Non-steroidal anti-inflammatory drugs (NSAIDS) that should be avoided completely: Indomethacin has significant CNS side effects Ketorolac (Toradol) can cause serious GI and renal effects
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Beers Criteria: Pain medications
Long-term use of NSAIDS Potential for GI bleed Renal failure Heart failure High blood pressure Meperidine (Demerol) has low oral efficacy, active metabolites and CNS effects
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Beers Criteria: Cardiovascular Agents
Digoxin Should not exceed mg/day except when treating atrial arrhythmias Decreased renal clearance, increase in toxic effects Amiodarone Associated with QT interval problems Lack of efficacy in older adults
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Beers Criteria: Disease Specific
Parkinson’s disease: metoclopromide and anti-psychotics Stress incontinence alpha-blockers Hyponatremia SSRIs Constipation calcium channel blockers Cognitive impairment Anticholinergics, antispasmodics, and muscle relaxants PD: cholinerigc and anati-dopaminergic propertiees
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2012 Update Released March 1, 2012 Removed medications that are no longer available Propoxyphene Additions to medications that should be avoided: Megestrol Glyburide Avoid sliding scale insulin American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication use in Older Adults, J Am Geriatr Soc, 2012
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2012 Update Additions to patients with particular disease state:
TZDs with CHF ACH inhibitors with hx of syncope SSRIs with hx of falls/fractures Added 3rd category: Medications that should be used with caution in the elderly All of which have ‘weak’ recommendations due to insufficient data Aspirin for primary prevention of cardiac events Lack of evidence of benefit versus risk in individuals aged 80 Use with caution in adults aged 80 Low Weak Dabigatran Greater risk of bleeding than with warfarin in adults aged 75; lack of evidence for efficacy and safety in individuals with CrCl < 30 mL/min aged 75 or if CrCl < 30 mL/ min Moderate Weak Prasugrel Greater risk of bleeding in older adults; risk may be offset by benefit in highest-risk older adults (e.g., with prior myocardial infarction or diabetes mellitus) aged 75 Antipsychotics Carbamazepine Carboplatin Cisplatin Mirtazapine Serotonin–norepinephrine reuptake inhibitor Selective serotonin Tricyclic antidepressants Vincristine May exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion or hyponatremia; need to monitor sodium level closely when starting or changing dosages in older adults due to increased risk Use with caution Moderate Strong Vasodilators May exacerbate episodes of syncope in individuals with history of syncope Use with caution Moderate Weak
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2012 Update Aspirin for primary prevention Dabigatran Prasugrel
Lack of benefit vs risk in patients >80 Dabigatran >risk of bleeding than warfarin in patients >75 Lack of evidence in patients with CrCl <30 Prasugrel Greater risk of bleeding; benefit may be greater in higher risk elderly (prior MI or DM) SIADH risk Risk of syncope with vasodilators
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Adverse Drug Events National surveillance of ED visits for outpatient ADE 2 year study, 21,000 ADEs reported 3,500 required hospitalization People >65 ED visits were twice that of those younger 4.9 per 1,000 vs. 2.7 per 1,0000 Hospitalizations nearly 7 times higher 1.6 per 1,000 vs per 1,000 JAMA. 2006;296:
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Adverse Drug Events Drugs for which regular outpatient monitoring is used to prevent acute toxicity accounted for 54% of hospitalizations Three medications caused 1/3 of ED visits Insulin Warfarin Digoxin
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Adverse Drug Events Cardiovascular medications
Psychotropic medications Antibiotics Anticoagulants NSAIDS Anti-seizure medications
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NSAID Use and GI Bleeds Several risk factors place the elderly population at increased risk for GI bleeds >75 years of age History of PUD History of GI bleed Concomitant use of warfarin Long term glucocorticoid use These patients warrant treatment with misoprostol or PPI JAGS.2007; 55:S383–S391.
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Medication Safety Prescribe one medication at a time
Start the dose low and titrate up slowly Use once daily dosing if possible Increases patient adherence Monitor the patient for response and adverse effects
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Upon discharge her medications have been changed
3 weeks later…. GF falls in the middle of the night while trying to get to the bathroom, she is subsequently admitted to the hospital Upon discharge her medications have been changed D/C lasix, diltiazem Start amiodarone 400 mg BID
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Given her current treatment plan would you recommend any changes?
Most current medication list Warfarin 5 mg daily Hydrochlorothiazide 25 mg daily Simvastatin 40 mg daily Amiodarone 400 mg BID
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Medication Safety Avoid drug-drug interactions that are associated with hospitalizations ACE Inhibitor plus Potassium sparing diuretic or potassium supplement Benzodiazepine Antidepressant and antipsychotics Warfarin New antibiotic, potent CYP inhibitors/inducers J Am Geriatr Soc. 1996;44(8):944–948
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It has been 1 month since hospital discharge and GF is returning to clinic for follow-up
She complains today of feeling very weak and have dark stools for the past week What is the most likely cause?
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Medication Safety Educate the patient Always assess compliance
Indication Why it is being used What they need to watch for Provide the patient with an up-to-date medication list at each visit Always assess compliance
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Medication Safety Always assess the Risk vs. Benefit
Appropriate medication use requires that benefits of therapy clearly outweigh the associated risks Benefit-to-risk ratio is unique to an individual; the very medication and dosage that helps one patient may harm another Remember that supplements, herbal and OTC agents can cause ADE Know what your patient is taking
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Its been three months and GF has been doing well
Its been three months and GF has been doing well. After her last discharge her amiodarone was stopped and metoprolol 25 mg BID was started Her INR has been stable between 2 and 2.5 since her GI bleed
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She presents to the ER today with signs and symptoms of a stroke
INR on presentation 1.4 Current medications Warfarin 5 mg daily Simvastatin 20 mg daily Hydrochlorothiazide 25 mg daily Metoprolol 25 mg BID St Johns Wort 1 tablet daily What is going on?
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Medication Safety Common herbal agents that can be hazardous
Garlic, gingko, green tea Increased bleeding time St. John’s Wort Increased clearance of medications metabolized by CYP-3A4 Chromium, gingko, nettle Hypoglycemia
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Quality Indicators All elders should have an up-to-date medication list in the medical record If an elder is prescribed a drug, then the prescribed drug should have a defined indication If an elder is prescribed a drug, then they should receive appropriate education about its use
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Quality Indicators If an elder receives a new prescription for a medication known to be high risk, proper monitoring should be performed
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Skills Medication reconciliation done at patient visit and hospitalization All prescribed medications Topical agents/transdermal patches OTC medications Herbal products and supplements Eye and ear drops Inhalers Drug list will be printed from Oacis each day when on inpatient service Some patients may NOT consider these as “drugs” and fail to provide a history of use: And they can be just as dangerous
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Medication Safety Is patient taking any over-the-counter medications or herbal supplements? Did you evaluate for harm and drug interactions?
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Skills Dose advisor should be used to ensure proper dosing for any new medication
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Skills Anytime a new medication is started the patient will be given a patient education sheet from Micromedex®
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Skills Any new medication prescribed to an elder will have the indication written in the directions This will aid in patient education and adherence
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Skills Any high risk medication will be appropriately monitored
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Medication Safety Is the patient currently on amiodarone therapy?
Is the patient on warfarin? Has the dose been appropriately adjusted? Is the patient on digoxin? Is the patient on simvastatin? Is the patient on 20mg/or less a day?
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Medication Safety If warfarin is prescribed
PT/INR should be drawn within 4 days for new starts Has a PT/INR been drawn in the past 30 days? If not, did you schedule an appointment with the PharmD today?
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Medication Safety If a hypoglycemic agent is prescribed
Has an A1C been checked within the last 6 months? If not, have you ordered one to be drawn today? Did you ask the patient about s/sx of hypoglycemia? If patient is experiencing s/sx of hypoglycemia, what did you do to address this issue? Reduce the dose of the hypoglycemic agent Refer to a CDE for further management
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Medication Safety Is patient currently receiving NSAID therapy?
Did you ask about the signs/symptoms of GI bleeding? Does patient have a history of PUD? Are they being treated with a PPI? If not, did you start one today?
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Medication Safety Is patient currently receiving digoxin?
Did you ask the patient about s/sx of digoxin toxicity? Did patient have s/sx of toxicity? If so, did you order a digoxin level today?
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Skills Each patient will receive an Aging Q3 pillbox to aid in patient adherence
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Patient Survey Surveyors to randomly select elders after check-out process occurs: Do you know who your doctor is? Were you given a medication list today? Were you started on a new medicine today? If so, were you given an information sheet on this medication? Do you know what this medicine is for?
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Take Home Points Review and reconcile medications at each visit:
Indication for each medication? Contraindications? (renal, dementia) Can I STOP any medication? Is the patient on any OTCs, herbals or supplements? Write indications on prescriptions Increase patient knowledge and compliance
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Take Home Points Avoid high-risk medications if possible
Beers criteria If high-risk medications is used, monitor appropriately When prescribing new medication Are there any drug-drug interactions? Is it appropriately dosed? Remember to look for ADE
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Questions???????????
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