* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Risperidone (Risperdal)
Survey
Document related concepts
Pharmacognosy wikipedia , lookup
Drug design wikipedia , lookup
Compounding wikipedia , lookup
Pharmaceutical industry wikipedia , lookup
Neuropharmacology wikipedia , lookup
Drug discovery wikipedia , lookup
Prescription costs wikipedia , lookup
Polysubstance dependence wikipedia , lookup
Intravenous therapy wikipedia , lookup
Prescription drug prices in the United States wikipedia , lookup
Pharmacokinetics wikipedia , lookup
Adherence (medicine) wikipedia , lookup
Theralizumab wikipedia , lookup
Electronic prescribing wikipedia , lookup
Transcript
Practical Prescribing for Vulnerable Community Living Elderly University of Cincinnati / Health Alliance Reynolds Geriatric Education Center Presentation Outline Review the challenges of prescribing for the Vulnerable seniors ; Examine risks factors for Adverse Drug Events; Propose strategies to improve prescribing outcomes; Suggest resources available for continual support in managing medications in seniors. 6 Prescribing Challenges Effective drug treatments for chronic illnesses have expanded, and many older people have multiple chronic illnesses Adverse drug reactions (ADEs) and drugdrug/drug-disease interactions increase as the number of prescribed medications increases Adherence to complex, multiple drug regimens is difficult: poor vision, poor memory, limited funds, etc. 7 Gaps in Our Understanding of Medication Use in the Elderly Safety and effectiveness of any given medication is not well studied in the aged Multiple concomitant medications adversely effect the safety and effectiveness of individual medications Multiple medical problems can adversely effect the outcomes of pharmacotherapy 8 Adverse Drug Events (ADEs) Use of multiple medications is the primary risk factor for experiencing an ADE Multiple chronic medical conditions increases the risk for ADEs Many ADEs are predictable and therefore preventable 9 Risk Factors for Adverse Drug Events in Older Patients > 6 concurrent chronic diagnoses >12 doses of medications/day > 9 medications Multiple Prescribing Physicians A prior ADE Low body weight Age >85 years Creatinine clearance <50 ml/minute 10 Adverse Drug Effect Cascade 11 15 Mrs. Janet Andrews An 86 year old patient comes to your office with her daughter. She last saw you more than a month ago when you completed a preoperative exam prior to an elective hip replacement. Mrs. Andrews was in the hospital for one week and in a nursing home for 3 weeks and is now back in her own home. 12 Pre-operative MedsMost concern? 1. Digoxin 2. Enalapril (Vasotec) 3. Warfarin 4. Tylenol PM 5. Dicyclomine (Bentyl) 6. More than one of the above 13 Post-operative Symptom: Confusion Least likely contributor? 1. Digoxin 2. Tylenol PM 3. Amiodarone (Cordarone) 4. Oxycodone 5. Warfarin 14 Post-operative Symptom: Poor Appetite Least likely contributor? 1. Digoxin 2. Enalapril (Vasotec) 3. Valdecoxib (Bextra) 4. Amiodarone (Cordarone) 5. Oxycodone 15 Post-operative Symptom: Constipation Least likely contributor? 1. Digoxin 2. Tylenol PM 3. Amiodarone (Cordarone) 4. Oxycodone 5. Warfarin 16 Post-operative Sign: Bradycardia Least likely contributor? 1. Digoxin 2. Enalapril (Vasotec) 3. Amiodarone (Cordarone) 4. Dicyclomine (Bentyl) 17 Today, would you discontinue or decrease the dose of one of these medications? 1. Digoxin 2. Enalapril (Vasotec) 3. Valdecoxib (Bextra) 4. Amiodarone (Cordarone) 5. None of the above 18 During future visits, would you discontinue or decrease the dose of one or more of these medications? 1. Dicyclomine 2. Ferrous sulfate 3. Oxycodone 4. Tylenol PM 5. Two of the above 6. Three of the above 7. All of the above 19 Benefit vs Risk 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. 20 Prescribing Suggestions with Vulnerable Seniors: Basic Strategies Prescribing ALL, indicated medications, may NOT be the best approach 2. Triage medications: 1. Start with most needed first, assess impact; then add second most important, etc. 3. Some conditions assumed to be “aging” can be ADEs – e.g., confusion, falls, incontinence 21 Helping Your Patients (I) Encourage Use of Patient Medication Logs Assess ability to take correctly Take advantage of Medication Adherence Aids Keep Costs Down 22 Helping Your Patients (II) Use One Drug to Treat Multiple Problems (For example, use antidepressant side effects) Avoid High Risk Medications Drug-Drug Interactions Drug-Disease Interactions 23 Where to get help UC/Health Alliance Reynolds Grant ‘Email Geriatrics Consultation’: [email protected] Net Wellness at http://www.netwellness.org American Geriatrics Society at http://www.americangeriatrics.org Medicaid Drug Benefit (AGS) at http://www.americangeriatrics.org/policy/medicare _info.shtml 24 Where to get help National Guideline Clearing House at http://www.guideline.gov Medscape at http://www.medscape.com Assistance Programs for Low Income older adults from Drug Manufacturers http://needymeds.com/ 25 Patient Medication Log Prescription drugs - from all providers Trans-dermal medications Inhalers OTC drugs Vitamins and Dietary Supplements Eye & ear drops Topical agents 26 Medication Adherence Aids 1. Prefer QD or BID regimens 2. Pill boxes to organize and provide reminders 27 Example 4 x 7 compliance Aid 28 Example 1x7 Compliance Aid 29 Using One Drug to Treat Multiple Problems 76 y.o. patient with depressive symptoms, weight loss, and insomnia. One drug could in theory treat all of these medical problems… Variation on this theme: Choose by the side effect you want or least desire when selecting otherwise “therapeutic equivalent” medications 30 Avoid Drug-Drug Interactions that are Associated with Hospitalization ACE-inhibitor plus… Potassium sparing diuretic or potassium Benzodiazepine plus… Antidepressant, antipsychotic, or another benzodiazepine Warfarin and new antibiotic prescription Diuretic plus….. Digoxin, nitrate, or another diuretic 31 Avoid Drug-Disease Interactions NSAIDs and History of Upper GI bleeding Anticholinergics medications: BPH/Bladder outlet obstruction Alzheimer’s Disease Chronic Constipation Benzodiazepines/Tricyclic antidepressants and Falling/Gait Disturbances 32 Help Patients Keep Costs Down (I) Prescribe a less expensive comparable brand or generic drug in the same drug class. Optimize dosing. (Does taking the total amount of the drug once daily save money and is it still effective?) Determine if cutting pills in half will reduce costs 33 Help Patients Keep Costs Down (II) Suggest using Mail Order for chronic medications. Use Assistance Programs for Low Income Seniors from Pharmaceutical Manufacturers http://needymeds.com/ 34 Prescribing for Vulnerable Seniors Clinical Topics Anti-cholinergic Medications Analgesics Sedative-Hypnotics Oral Agents for Type II Diabetes Dietary Supplements 35 Avoid Medications with High Anti-Cholinergic Properties (I) Antihistamines in general and diphenhydramine (Benadryl) in particular Omnipresent in OTC sedatives, cough and cold, sinusitis etc. For antihistamines use loratadine (Claritin) or fexofenadine (Allegra) 36 Avoid Medications with High Anti-Cholinergic Properties (II) Tricyclic Antidepressants, Anti-spasmotics, Anti-psychotics, Anti-parkinsonian and muscle relaxants, Incontinence medications 37 Analgesics-Choose Carefully (I) Acetaminophen – 1st Choice for Chronic Pain NSAIDS - COX-2 or Non-selective –Use cautiously ONLY for short term treatment, avoid for chronic pain or add PPI Tramadol (Ultram) – Possible 2nd Choice for chronic pain 38 Analgesics-Choose Carefully (II) Use scheduled narcotics to reduce chronic pain Avoid: Propoxyphene, meperidine, trans-dermal agents AGS Chronic Pain Guidelines at http://www.americangeriatrics.org/education/manage_pers_p ain.shtml Partners Against Pain at http://www.partnersagainstpain.com/index-mp.aspx?sid=3 39 Sedative/hypnotics (I) Trazodone GABA selective agents – zolpidem (Ambien) or zaleplon (Sonata) 40 Sedative/hypnotics (II) Non-GABA selective benzodiazepine Lorazepam Oxazepam Temazepam Choose a moderate half-life agent if need regularly All can cause falls, memory impairment, “retrograde” amnesia, tolerance and withdrawal 41 Oral Agents for Diabetes (I) How tight to control frail elderly? If insulin used, do you need oral agent? Insulin sensitizers – Actos, Avandia-use cautiously May increase CHF symptoms, peripheral edema 42 Oral Agents for Diabetes (II) Hypoglycemia more likely to occur with metformin and/or beta-blockers Lactic acidosis more likely with metformin when used in seniors with renal impairment Consult Am Assoc Clinical Endocrinologists at http://www.aace.com/clin/guidelines/ 43 Dietary Supplements (I) St. John’s Wort can increase drug metabolism (P450/CYP3A4) “G-Team” all have antiplatelet effects Ginkgo Biloba; Garlic; Ginger Saw Palmetto – no reported drug interactions Kava Kava – associated with hepatoxicity 44 Dietary Supplements (II) Echinacea – avoid long term use; agent decreases immune response Resources: Natural Medicine Database http://www.naturaldatabase.com/ The Prescriber’s Letter at http://www.prescribersletter.com 45 Practical Prescribing for Vulnerable Community Living Older Adults Part Two Managing Common Clinical Problems 46 Mrs. Janet Andrews Mrs. Andrews returns for f/u one month after her last visit. A number of her medications have been discontinued or dosing was reduced. In general she is doing better. Less confused, no constipation, improving hydration and anemia. She continues to have trouble walking and sleeping. Although her appetite is better she has lost another 2 lbs to 108 lbs (10 lbs in the last 2 months). She has added several dietary supplements to improve her medical problems. New symptoms are increasing anxiety and agitation, and easy bruising. 47 Continuing Weight Loss / Poor Appetite: LEAST Likely Contributor 1. Digoxin 2. Ferrous sulfate 3. St John’s Wort 4. Kava kava 5. Anxiety / agitation 6. Depressive symptoms 48 Minor depression with anxiety and insomnia: BEST treatment choice? 1. St Johns Wort 2. Fluoxetine extended release (Prozac weekly) 3. Escitalopram (Lexapro) 4. Mirtazapine (Remeron) 5. Trazodone (Desyrel) 49 Potentiating Warfarin / Easy Bruising: LEAST Likely 1. Tylenol 2. Gingko Biloba 3. Garlic 4. Glucosamine/chondrotin 5. Limited dietary vitamin K 50 Dietary Supplements (I) St. John’s Wort can increase drug metabolism (P450/CYP3A4) “G-Team” all have antiplatelet effects Ginkgo Biloba; Garlic; Ginger Saw Palmetto – no reported drug interactions Kava Kava – associated with hepatoxicity 51 Dietary Supplements (II) Resources: Natural Medicine Database http://www.naturaldatabase.com/ Herb Med at http://www.herbmed.org/about.asp The Prescriber’s Letter at http://www.prescribersletter.com 52 Insomnia: Which medication would be best to recommend?* 1. Trazodone 50 mg po qHS 2. Zolpidem (Ambien) 10 mg take ½ tablet (5 mg) po qHS PRN 3. Temazepam 15 mg capsule po PRN 4. Mirtazepine (Remeron) one-half of 30 mg tablet (15 mg) qHS 5. Zalepion (Sonata) 5 mg po qHS prn early awakening * Along with counseling on good sleep hygiene (avoid naps, improve sleep environment schedule daytime activity etc) 53 Persistent Pain: 5 on scale of 10 MODIFY or ADD 1. Propoxyphene/acetaminophen (Darvocet)* 2. Hydrocodone/acetaminophen (Vicodin)* 3. Naproxen (Naprosyn) 4. Celecoxib (Celebrex) 5. Fentanyl patch (Duragesic) *These choices require discontinuation of acetominophen 1 gram four times a day. 54 Analgesics-Choose Carefully Use scheduled narcotics to reduce chronic pain Avoid: Propoxyphene, meperidine, trans-dermal agents AGS Chronic Pain Guidelines at http://www.americangeriatrics.org/education/manage_pers_pain.shtml Partners Against Pain at http://www.partnersagainstpain.com/index-mp.aspx?sid=3 55 Mr. Robert Jacobs An 82 year old patient comes to your office with his wife for a follow-up visit. He is returning from a 2-month stay in Florida and has not seen you for three months. While he was in Florida, Mr. Jacobs was evaluated in the emergency room for an episode of dizziness and delirium. He was treated for a UTI and several medications were adjusted. Today, Mr. Jacobs remains dizzy, is unsteady when he walks, is still confused, is sleepy, has urinary frequency, knee pain, and a poor appetite. 56 Dizziness and Unsteadiness: Least Likely Contributor 1. Terazosin (Hytrin) 2. HCTZ 3. Lisinopril 4. Rosiglitazone (Avandia) 5. Risperidone (Risperdal) 57 Confusion and Sleepiness: Most Likely Contributor 1. Celecoxib (Celebrex) 2. Donepezil (Aricept) 3. Risperidone (Risperdal) 4. Lisinopril 5. Glipizide 58 Poor Appetite: Least Likely Contributor 1. Donepezil (Aricept) 2. Terazosin (Hytrin) 3. Celecoxib (Celebrex) 4. Risperidone (Risperdal) 5. Tolterodine (Detrol) 59 Urinary Frequency: Most Likely Contributor 1. Terazosin (Hytrin) 2. Celecoxib (Celebrex) 3. Tolterodine (Detrol) 4. Glipizide 5. Risperidone (Risperdal) 60 Today, would you discontinue or decrease the dose of one of these medications? 1. Decrease Aricept dose 2. Decrease Hytrin dose 3. Discontinue Celebrex 4. Discontinue Detrol 5. Decrease Lisinopril dose 61 During future visits, would you discontinue or decrease the dose of one or more of these medications? 1. Terazosin (Hytrin) 2. Tolterodine (Detrol) 3. Celecoxib (Celebrex) 4. Risperidone (Risperdal) 5. Two of the above 6. Three of the above 7. All of the above 62 Oral Agents for Diabetes (I) How tight to control frail older adult? If insulin used, do you need oral agent? Insulin sensitizers – Actos, Avandia-use cautiously May increase CHF symptoms, peripheral edema 63 Oral Agents for Diabetes (II) Hypoglycemia more likely to occur with metformin and/or beta-blockers Lactic acidosis more likely with metformin when used in older adults with renal impairment Consult Am Assoc Clinical Endocrinologists at http://www.aace.com/clin/guidelines/ 64