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Polypharmacy
Authors name and affiliation
ACKNOWLEDGEMENT
These slides were designed by Dr. Nancy Ordonez as part
of her faculty role in the HRSA sponsored Houston
Geriatric Education Center. Please credit her if utilizing
these slides and recognize the Health Resource Service
Administration for their support of our geriatric education
program.
Nancy Ordonez., Pharm.D., BCPS
Clinical Associate Professor
Assistant Dean for Experiential Programs
University of Houston College of Pharmacy
Faculty
Houston Geriatric Education Center
Funded By
This project is funded by a grant from the
Health Resources and Services
Administration (HRSA) of the Department of
Health and Human Services. The grant was
initially funded in 2007 with renewed
funding for five years beginning in 2010.
(Grant #UB4HP19058). The grant ended in
June, 2015.
3
Learning Objectives
• Successful students will be able to:
– Identify and describe age-related physiological changes
that influence pharmacokinetic and pharmacodynamic
aspects of pharmacotherapy.
– Discuss adverse drug reactions as they relate to older
adults.
– Identify iatrogenic problems with multi-geriatric
syndromes and their medication regimens.
– Discuss issues of medication compliance in older adults.
– Describe general guidelines for prescribing appropriately
and avoiding polypharmacy.
Statistics
• Those 65 year and older represent 12.6% of the US population,
approximately one in eight Americans.
• The elderly account for nearly 30% of the nation’s health care
expenditures and 25% of drug expenditures.
• A survey of non-institutionalized participants found that 12% of
women aged above 65 years took at least 10 medications and 23%
took at least five prescription drugs.
• The average US nursing home resident uses seven different
medications each month, and about one-third of residents have
monthly drug regimens of nine or more medications.
• By 2030, it is estimated that one in five Americans (71.5 million) will
be over the age of 65 years.
Ramaswamy R, et al. J Eval Clin Pract. 2010
20 yrs
Function
al
Capacity
80 yrs
“Function/Dysfunction” line
Age …… ……Disease Process >>>
Flaherty JH. Clin Geri Med 1998
Age Related Changes
• Pharmacokinetic
–
–
–
–
Absorption
Distribution
Metabolism
Excretion
• Pharmacodynamic
–
–
–
–
Changes in receptor affinity
Changes in receptor number
Changes in response
Changes in homeostasis control
Disease States that Alter Pharmacokinetic and
Pharmacodynamics
• Renal Failure
– Increases distribution
– Decreases elimination
– Alters distribution
– Decreases baroreceptor sensitivity
• Congestive Heart Failure
– Increases distribution
– Decreases elimination
• Liver Disease
Intrinsic Properties of Medications
• Negative
–
–
–
–
–
Long biological half-life
Extensive oxidative metabolism (P450)
Many active metabolites
Highly protein bound
Lipophilic
• Positive
–
–
–
–
Short biological half-life
Excreted unchanged or conjugative metabolism
Minimal protein binding
Hydrophilic
Definition of Polypharmacy
• Strictly defined as the use of multiple medications
– Threshold for the total number qualifying varies in the
literature (2-10)
• Comprehensively defined as the use of
medications with duplicative indications, drugdrug interactions, disease-drug interactions, in
adequate attention to pharmacokinetic/
pharmacodynamic principles, and/or no
indication
Lee RD. J Am Board Fam Pract. 1998;11(2):140-144.
Monane M, et al. West J Med. 1997;167:233-237.
Factors Contributing to Polypharmacy
• Increasing age
• Multiple symptoms
• Multiple medical problems
• Copious prescribing
• Multiple providers
Factors Contributing to Polypharmacy
(continued)
• Lack of primary care provider to coordinate
• Use of multiple pharmacies
• Drug regimen changes
• Hoarding of medications
• Self-treatment
Indicators of Polypharmacy
• Prescribing medications with no apparent
indication
• Use of medications in same drug category
• Concurrent use of interacting medications
• Prescribing drugs contraindicated in the elderly
• Ordering inappropriate dosages
• Using a drug to treat an ADR
• Clinical improvement following discontinuation of
medications
The Prescribing Cascade
INITIAL CONDITION
THERAPY
NEW SYMPTOM
SUBSEQUENT RX
ARTHRITIS
NSAID
DEPRESSION
 Blood
Pressure
BP Med
Tricyclic
Antidepressant
CONSTIPATION
AGITATION
LAXITIVE USE
ANTIPSYCHOTIC
ExtraPyramidal
Syndromes
PARKINSONS
MED
Gurwitz JH. P&T. 1997
Potentially Inappropriate Prescribing
(PIP)
• Defined as prescribing that poses more risk than
benefit to the individual.
• Using medications either have no clear evidence-based
indication, carry a substantially higher risk of ADE or
are not cost-effective.
• The risk of adverse drug event (ADE) resulting from PIP
ranges from weakness, to falls and fractures, even to
life threatening events.
• The Beers criteria is one of the most widely cited
guidelines.
• Other guides exist to determine appropriateness of
therapy.
Ramaswamy R, et al. J Eval Clin Pract. 2010
Potentially Inappropriate Prescribing
(PIP)
• Studies show prevalence of at least one inappropriate
medication being prescribed for up to 40% of nursing home
residents and 21% of community-dwelling elderly.
• The cost of medication related problems has been estimated
to be $76.6 billion to ambulatory care, $20 billion to hospitals,
and $4 billion to nursing home facilities.
• If medication-related problems were ranked as a disease by
cause of death, it would be the fifth leading cause of death in
the United States.
Ramaswamy R, et al. J Eval Clin Pract. 2010
Beer’s Criteria
Fick DM, et al. Arch Intern Med. 2003;163:2716-24
Medication Appropriateness Index
Each question is answered using a three-point Likert scale. The first two questions
receive a weighting of (3), the next four a weighting of (2), and the last four a
weighting of (1).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Is there an indication for the drug?
Is the medication effective for the condition?
Is the dosage correct?
Are the directions correct?
Aare the directions practical?
Are there clinically significant drug–drug inter-actions?
Are there clinically significant drug–disease/condition interactions?
Is there unnecessary duplication with other drugs?
Is the duration of therapy acceptable?
Is the drug the least expensive alternative compared to others of
equal utility?
Fitzgerald LS, et al. Ann Pharmacother. 1997;31:543-8.
Screening Tool of Older Persons' Potentially
Inappropriate Prescriptions (STOPP)
• STOPP is comprised of 65 clinically significant criteria
for potentially inappropriate prescribing in older
people. It incorporates commonly encountered
instances of potentially inappropriate prescribing in
older people.
– includes drug-drug and drug-disease interactions, drugs
which adversely affect older patients at risk of falls and
duplicate drug class prescriptions.
– criteria are arranged according to relevant physiological
systems.
– each criterion is accompanied by a concise explanation as
to why the medication is potentially inappropriate.
Levy HB, et al. Ann Pharmacother. 2010 ;44(12):1968-75.
Screening Tool to Alert Doctors to the
Right Treatment (START)
• START consists of 22 evidence-based prescribing
indicators for commonly encountered diseases in older
people. The tool helps to identify prescribing omissions
(medication indicated, but not prescribed).
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–
–
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Cardiovascular system
• Warfarin in the presence of chronic atrial fibrillation, where there is no contraindication
to warfarin
• Beta blocker in chronic stable angina, where no contraindication exists
Respiratory system
• Inhaled steroid in moderate-to-severe asthma or COPD, where reversibility of airflow
obstruction has been shown
Central nervous system
• L-dopa in idiopathic Parkinson’s disease with definite functional impairment and
resultant disability
Gastrointestinal system
• Proton pump inhibitor in the presence of chronic severe gastro-esophageal acid reflux
Locomotor system
• Calcium and vitamin D supplement in patients with known osteoporosis
Endocrine system
• ACE inhibitor or Angiotensin Receptor Blocker in diabetes with nephropathy
Levy HB, et al. Ann Pharmacother. 2010 ;44(12):1968-75.
Strategies to Optimize Prescribing
• Educational Interventions
– Small group workshops
– Three step approach – quarterly reports, biannual onsite visits, and
annual meetings
• Computerized support systems
– Dispensing and Ordering
• Pharmacist interventions
– Physician and Patients
• Geriatric Medicine Services
• Multidisciplinary Teamwork
• Regulatory Polices
• Medication Therapy Management
Kaur S, et al. Drugs Aging 2009;26(12):1013-28.
Steinman M, Hanlon JT. JAMA 2010;304(14):1592-1601.
Medication Adherence in the Elderly
• Complex and there is no “one size fits all”
solution
– Patient Specific Factors
– Medication Specific Factors
– Prescriber Specific Factors
– Health Plan Specific Factors
• Multimodal interventions that address
behavioral aspects provide more benefit than
education alone.
Conn VS, et al. The Gerontologist 2009;49(4): 447–62.
Proposed Strategies to Increase
Adherence
• Short-term Treatment <
2 weeks
– Counseling on
importance
– Written instructions
– Reminder packaging
• Long-term Treatment
• Combinations of:
– Instruction/Instruction
materials
– Simplify regimen
– Counseling/Reminders
– Cueing to daily events
– Reinforce/Reward
– Patient self monitoring
– Involve family/significant
others
Haynes et al. JAMA, 288:2880-83.
Multimodal Approach
Patient
•Must engage in essential behavior
•Decide to control risk factors
•Negotiate with provider
•Adopt and maintain behavior
•Monitor progress towards goals
•Resolve barriers to goals
•Must communicate with provider
Provider
•Must foster effective communication
Healthcare Organization
•Healthcare organization must:
•Provide clear and direct message
•Develop supportive environment
•Include the patient in decisions
•Provide tracking and reporting systems
•Incorporate behavioral strategies
•Provide education/training for providers
•Must document and respond to progress
•Create evidence-based practice
•Assess adherence each visit
•Develop reminder system
•Provide adequate reimbursement for time
•Healthcare organization must adopt
systems to rapidly and efficiently incorporate
innovations into practice
Circulation ;95:1085-1090
Technology and Informatics to the
Rescue?
• E-prescribing
– Provide point-of-care alerts
– Decrease cost burden to patient
– Improve reimbursement to provider
– Optimize medication utilization for health plan
• Physician Order Entry
• Medical Home Model
Discussion