Use caution in the elderly: Disclosures review of safe and - PDF document

1/21/2018 Use caution in the elderly: Disclosures review of safe and effective • I have no disclosures or conflicts of interest medication use in older patients related to this presentation John T. Holmes, PharmD, BCPS Assistant Professor of Family Medicine and Pharmacy Practice Idaho State University DB is a 75-year-old female who resides in Idaho City and has When designing an intervention to improve inappropriate a history of hypertension, diabetes, depression and prescribing and reduce ADEs, which of the following dyslipidemia. She currently takes glimepiride 2 mg by interventions is likely to be most effective? mouth daily, metformin 500mg by mouth daily, lisinopril 10 mg by mouth daily, atorvastatin 20mg by mouth daily, A. Integrate the Beer’s Criteria into an electronic medical record sertraline 100mg by mouth daily and aspirin 325mg by prescribing alerts that requires prescribers to use alternative mouth daily. Which of the following are risk factors that therapies when attempting to prescribe Beer’s list medications to elderly patients. may contribute to DB having an ADE? B. Utilize several interventions including annual pharmacist A. Polypharmacy medication review, prescriber audit and feedback, and electronic medical record warnings alerting prescribers to potential B. History of depression, diabetes, and dyslipidemia inappropriate medication use in the elderly. C. Rural residence C. Prescriber education on START/STOPP and Beer’s Criteria. D. Glimepiride use D. Accurate medication reconciliation performed at every provider visit and up-to-date medication list provided to patient. E. All of the above Learning Objectives Institute of Medicine • Employ individual and population-based tools to Pharmaceuticals are the most common medical improve appropriate medication use in older adults. intervention, and their potential for both help and • Recognize and classify medication-related problems harm is enormous. Ensuring that the American people in the elderly. get the most benefit from advances in pharmacology is a critical component of improving the national health • Design an evidence-based strategy to improve the safety and effectiveness of medications in older care system adults. 1

1/21/2018 The Problem The Problem • 84% of older adults take ≥1 prescription medication • Mean prevalence of ADRs in elderly is around 11% – Range is 5.8% – 46.3% • About 35% of older adults take ≥5 prescription • Prevalence of ADRs leading to hospitalization is 10% medications – 38% take over-the-counter medications • One in six hospital admissions for older people due – 64% take herbal medications to an ADE • Estimated that 15% of older adults at risk for major – In patients >75 years old, one in three admission due to ADE drug-drug interaction Qato et al. JAMA Intern Med. 2016 Apr;176(4):473-82. Qato et al. JAMA Intern Med. 2016 Apr;176(4):473-82. Alhawassi et al. Clin Interv Ageing. 2014;9:2079-2086. Alhawassi et al. Clin Interv Ageing. 2014;9:2079-2086. Definitions Risk Factors for ADRs in Elderly • Medication-Related Problems (MRP) • Medication-Related Factors – Event or circumstance involving medication therapy – Number of medications that actually or potentially interferes with an optimum – Antihypertensive medications outcome for a specific patient – Antithrombotic/Anticoagulant medications – Antibacterials • Inappropriate Prescribing (IP) – NSAIDs – Use of medications that pose more risk than equally or – Antidiabetic medications more effective but lower-risk alternative therapy – Psycholeptics – Drug-Drug Interactions Alhawassi et al. Clin Interv Ageing. 2014;9:2079-2086. Risk Factors for ADRs in Elderly Risk Factors for ADRs in Elderly • Disease-Related factors • Patient-Related Factors – Multimorbidity – Greater Age – Cardiovascular disease – Female – Diabetes – Rural residential location – Cancer – Depression – Socioeconomic status – Impaired renal function • Other Factors – Dementia – History of Falls – Dyslipidemia – Limitations in activities of daily living – Elevated WBC – Liver disease Alhawassi et al. Clin Interv Ageing. 2014;9:2079-2086. Alhawassi et al. Clin Interv Ageing. 2014;9:2079-2086. 2

1/21/2018 Reasons for ADEs in Elderly Reasons for ADEs in Elderly • Pharmacokinetic/Pharmacodynamic Changes • Polypharmacy – Changes in volume of distribution of several medications – Higher prevalence of chronic disease and comorbidity • Reduction in lean muscle mass and water content – Strongly predictive of ADRs • Increase in proportion of total body fat • 2 concurrent medications  13% risk of ADR – Reduced serum albumin • 4 concurrent medications  38% risk of ADR – Reduced liver mass and perfusion • 7 concurrent medications  82% risk of ADR – Prescribing cascade – Reduced glomerular filtration rate • Antipsychotic  metabolic disease  medications for diabetes, – Altered pharmacodynamic responses hypertension, dyslipidemia, obesity, etc. • Thiazide diuretic  gout  medication for gout Hajjar et al. Am J Geriatr Pharmacother. 2007;5: 345 – 51. Lavan et al. Ther Adv Drug Saf . 2016 Feb;7(1):11-22 Goldberg et al. Am J Emerg Med 1996;14:447-450. Categories of Inappropriate Prescribing Inappropriate Prescribing • The use of a drug: • 50% of older adults take one or more medications – That has wrong indication that are not necessary – That has no indication • IP occurs in: – That has a high risk for Adverse Drug Events (ADEs) – At higher frequency/dose than recommended – 12-40% of nursing home residents – That is unnecessarily expensive – 14-23% of community-dwelling older people (Gallagher et – For longer or shorter duration than clinically indicated al. 2007) • Failure to prescribe appropriate drug therapy for • Increase risk ADEs, hospitalization, and death irrational or ageist reasons (e.g. warfarin) • Greater healthcare costs • Use of multiple medication with documented drug- • 50% of ADRs in older adults due to inappropriate drug interactions or drug-disease interactions prescribing (Lindley et al. 1992) Measuring Inappropriate Prescribing • Measuring prescribing quality usually focused on one of the following (rarely all): – Avoidance of inappropriate medications – Appropriate use of indicated medications – Monitoring side effects and/or drug levels – Avoidance of drug-drug interaction – Involvement of patients and their values • Interventions to improve prescribing have mixed results for health outcomes (i.e. mortality) and costs Spinewine et al. Lancet. 2007;370(9582):173 Institute of Medicine. Preventing Medication Errors . Alldred et al. Cochrane Database Syst Rev. 2016;2:CD009095 Washington, DC: National Academies Press; 2007 3

1/21/2018 Predicting ADRs Drug Utilization Review Tools • GerontoNet ADR Risk Score • Explicit (criterion-based) Variable Points – Developed using expert opinion, consensus, published reviews ≥4 Comorbid Conditions 1 – Drug or disease-oriented Heart Failure 1 – Applied with little or no clinical judgment Liver Disease 1 – May not take into account all factors that define high Number of Drugs quality indicators for each patient ≤ 5 0 – Do not address comorbidity or patient preference 5 – 7 1 – Examples ≥ 8 4 • Beer’s Criteria • Screening Tool of Older Persons Prescriptions (STOPP) Previous ADR 2 • Screening Tool to Alert doctors to the Right Treatment (START) Renal Failure 1 Spinewine et al. Lancet. 2007;370(9582):173 Onder et al., Arch Intern Med. 2010 July;170(13):1142-1148 Which of the following do you have Drug Utilization Review Tools experience using? • Implicit (judgment-based) – Employ patient-specific information and evidence A. START/STOPP – Focus on patient rather than drugs or disease B. Beer’s Criteria – Account for patient preferences and are most sensitive C. Medication Appropriate Index (MAI) – Time-consuming D. Both START/STOP and Beer’s Criteria – Depends on user’s knowledge and attitudes E. START/STOPP, Beer’s Criteria, and MAI – Low reliability – Example: F. None of these • Medication Appropriateness Index (MAI) Spinewine et al. Lancet. 2007;370(9582):173 START / STOPP STOPP Examples • Screening Tool to Alert doctors to Right Treatment • Indication of Medication (START) – Any drug prescribed without an evidence-based clinical – 34 START Criteria indication • Screening Tool of Older Persons’ potentially – Any drug prescribed beyond recommended duration inappropriate Prescriptions (STOPP) – Any duplicate drug class prescription (optimization of monotherapy) – 81 STOPP Criteria • Cardiovascular – Overlaps with Beer’s Criteria – Digoxin for heart failure with normal systolic ventricular function • Developed in 2008; last updated in 2014 – Loop diuretic as first-line treatment for hypertension • Includes brief explanation about why the prescribing practice is potentially inappropriate 4