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Transcript
Medication Use and Safety in the Elderly Amy N. Thompson, PharmD, BCPS ACOVE 5 Medical University of South Carolina 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 Challenges of Prescribing for Older Adults • Multiple medical conditions • Multiple prescribers • Adherence and cost • Lack of evidence • Supplements, herbals and over-thecounter medications • Different metabolisms and distribution 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 Distribution • Decreased body water – 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 Metabolism • Slowed phase I metabolism – Oxidation, reduction, dealkylation • Unchanged phase II metabolism – Conjugation, acetylation, methylation 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% 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 Toxic Response Therapeutic Window Therapeutic Response Age 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 • 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 • One week later: – GF presents to the ER with bilateral LE edema – Given a prescription for Lasix 20 mg daily • What is going on? 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 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 Adverse Drug Events • Linked to preventable problems in the elderly, such as: – Depression – Constipation – Falls – Immobility – Confusion – Hip fractures Arch Intern Med.2003;163:271625. 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):61631. 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 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 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 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 Beers Criteria: Cardiovascular Agents • Digoxin – Should not exceed 0.125 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 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 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 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 2012 Update – Aspirin for primary prevention • 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 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. 0.23 per 1,000 JAMA. 2006;296:1858-1866 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 Adverse Drug Events • Cardiovascular medications • Psychotropic medications • Antibiotics • Anticoagulants • NSAIDS • Anti-seizure medications 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. 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 • 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 • 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 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 • 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? Medication Safety • Educate the patient – 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 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 • 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 • 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? 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 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 Quality Indicators • If an elder receives a new prescription for a medication known to be high risk, proper monitoring should be performed 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 Medication Safety • Is patient taking any over-the-counter medications or herbal supplements? – Did you evaluate for harm and drug interactions? Skills • Dose advisor should be used to ensure proper dosing for any new medication Skills • Anytime a new medication is started the patient will be given a patient education sheet from Micromedex® http://www.thomsonhc.com.ezproxy.musc.edu/carenotes/librarian Skills • Any new medication prescribed to an elder will have the indication written in the directions – This will aid in patient education and adherence Skills • Any high risk medication will be appropriately monitored 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? • Has the dose been appropriately adjusted? – Is the patient on simvastatin? • Is the patient on 20mg/or less a day? 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? 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 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? 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? Skills • Each patient will receive an Aging Q3 pillbox to aid in patient adherence 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? 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 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 Questions???????????