Polypharm

Question 1

What are the risks of adverse drug events in persons 65 and older?

Answer 1

• 13% w/ 2 or more meds
• 58% w/ 5 meds
• 82% w/ 7 or more meds

Question 2

What is polypharmacy?

Answer 2

• 4 or more medications
• more meds the pt takes, the greater the chance of having an adverse drug event
• adverse drug events are responsible for about 100,000 hospitalizations/yr

Question 3

What are some examples of adverse drug events?

Answer 3

• falls
• orthostatic hypotension
• heart failure
• delirium
• MC causes of death from adverse drug rxns:
  GI bleeding, intracranial bleeding and renal failure

Question 4

Why is polypharm such a problem?

Answer 4

• b/c new prescriptions are being made but the old prescriptions that may be potentially inappropriate aren’t being d/c (EMRs help decrease inappropriate Rx but don’t alert when to d/c old meds, has alert fatigue)

Question 5

What are the MC drugs assoc w/ adverse events?

Answer 5

• antithrombotics
• antidiabetics
• diuretics
• NSAIDs

Question 6

Common sxs that may be secondary to adverse drug rxn?

Answer 6

• falls
• orthostatic hypotension
• heart failure
• delirium

Question 7

How does drug metabolism differ in older adults?

Answer 7

• liver:
  hepatic blood flow decreases by 40%, decreased 1st pass metabolism: warfarin, BZDs, opiates reqr smaller doses
• kidneys:
  renal blood flow can decrease by about half at 80 yo
• decreased lean body wt to body fat ratio - alters the distribution of drugs in body compartments
• decreased serum protein: drugs that are protein bound are now free to act resulting in small dose needed for desired effect
• substance abuse: 10% are problems drinkers, can cause a change in drug metabolism

Question 8

How can we prevent polypharm?

Answer 8

• more than half of all hosp admissions for adverse drug rxns are potentially preventable
• med review and reconciliation at each visit
• include drug rxn in your ddx for new complaints
• be familiar w/ Beers criteria
• STOPP: screening tool of older persons’ potentially inappropriate rxs
• START: screening tool to alert prescribers to right tx

Question 9

What is the Beers criteria?

Answer 9

• MC used criteria, most recent revision 2015
• sponsored by American Geriatrics Society
• 2 lists of meds to be avoided in older adults
• 1 list of meds that should be used w/ caution

Question 10

What are some examples of meds on the Beers criteria?

Answer 10

• Nitrofurantoin (macrobid)- potential for pulm toxicity, lack of efficacy w/ CrCl less than 60 ml/min due to inadequate drug concentration in urine
• digoxin in doses over 125 mcg: increased risk of toxicity, due to decreased renal clearance and decreased protein binding
• sliding scale insulin: higher risk of hypoglycemia w/o improvement of hyperglycemia management
• sulfonylureas: glyburide- prolonged hypoglycemia
• Non-cox-selective NSAIDs: increased risk of GI bleeding, PUD, use of PPI or misoprostol decreaes risk

Question 11

What are drugs that may worsen constipation?

Answer 11

• antimuscarinics for urinary incontinence: oxybutynin, tolterodine,
• nondihydropyridine CCBs: verapamil, diltiazem
• 1st gen antihistamines

Question 12

What drugs may causes SIADH or exacerbate underlying syndrome?

Answer 12

• SNRIs
• SSRIs
• antipsychotics

Question 13

What are inappropriate drugs to use in elderly?

Answer 13

• diphenhydramine (benadryl)
• amitriptyline (elavil)
• aprazolam (xanax)
• diazepam (valium)
• chlorpropamide and glyburide
• digoxin in doses over 0.125
• Gi antispasmodics: belladonna, dicyclomine, hyoscyamine
• meperidine (demerol)
• methyldopa (aldomet)

Question 14

Why should benadryl be avoided in older pop?

Answer 14

should generally be avoided in older adults, causes dry mouth, confusion, urinary retention, constipation, source of in hospitatl morbidity/delirium, is in many OTC products for sleep/URI/allergy

Question 15

Why should digoxin be avoided in the elderly?

Answer 15

• can cause anorexia, confusion even at therapeutic drug levels, renal excretion can change over time as age related renal fxn declines
• 0.125 mg/day most often adequate

Question 16

What is the STOPP criteria?

Answer 16

• 65 clinically significant criteria for potentially inappropriate rx in older adults
• overlaps w/ Beers criteria

Question 17

What is the START criteria?

Answer 17

• study done to determine if meds that are approp according to EBM were omitted
• 600 adults admitted to teaching hospital
• 58% of pts had drug omissions w/o documentation as to why med was not offered or rx
• MC ommissions:
  statins in atherosclerosis (26%)
  warfarin in chronic a fib (9.5%)
  anti-platelet therapy in arterial disease (7.3%)
  calcium/vit d supplementation in sx osteoporosis (6%)

Question 18

Choosing Wisely initiative?

Answer 18

• initiative of American board of internal medicine
• 2 lists of 5 things physicians and pts should question, addresses screening tests, meds
• don’t use antipsychotics as first choice to tx behavioral and psychological sxs of dementia
• avoid using meds to achieve A1C of less than 7.5% in most adults 65 and older
• don’t use benzos or other sedative hypnotics in older adults as 1st choice fo insomnia, agitation, or delirium
• don’t use antimicrobrials to tx bacteriuria in older adults unless specific UT sxs are present
• don’t rx cholinesterase inhibitors for dementia w/o periodic assessment for perceived cognitive benefits and adverse GI effects
• avoid using Rx appetite stimulants or high calorie supplements for tx of anorexia or cachexia in older adults
• don’t rx a med w/o conducting a med review

Question 19

How can we reduce adverse drug effects?

Answer 19

• look for meds that were started at young age that might now need to be adjusted - ex: atenolol
• meds used as an inpt are often at higher doses than needed for chronic therapy - diuretics
• avoid adding meds to tx adverse effects of another med if possible - instead decrease dose, change or DC drug
• capture all herbal and OTC meds that pt is taking “brown bag”
• if drug levels are subtherapeutic must verify compliance prior to increasing dose
• drugs for pain, behavior and cognition need to be regularly assessed for response and try to avoid long term tx w/ these
• start low and go slow
• have pt return for regular f/u to monitor for ADE, avoid starting 2 new meds in same pt at one time
• incorporate a standardized method for med review (Beers, START, STOPP)