* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download When to Spare Some Pharmaceutical Care
Survey
Document related concepts
Drug design wikipedia , lookup
Pharmaceutical marketing wikipedia , lookup
Drug discovery wikipedia , lookup
Compounding wikipedia , lookup
Polysubstance dependence wikipedia , lookup
Pharmacokinetics wikipedia , lookup
Neuropharmacology wikipedia , lookup
Pharmaceutical industry wikipedia , lookup
Prescription drug prices in the United States wikipedia , lookup
Prescription costs wikipedia , lookup
Intravenous therapy wikipedia , lookup
Drug interaction wikipedia , lookup
Adherence (medicine) wikipedia , lookup
Transcript
When to Spare Some Pharmaceutical Care Jovino Hernandez PharmD Clinical Manager Winter Haven Hospital Pharmacy Services Goals Recognize the incidence of polypharmacy Identify The Risk Associated with Polypharmacy Classify Agents that Pose the Most Risk to the Elderly Population Develop Strategies to Decrease Polypharmacy Introduction All drugs can be considered “poisons” The more we ingest, the more apt we are to have issues Clinical guidelines often call for multiple medications Appropriate medication use beneficial to patients Challenge is not to tip the scale toward adverse events What is Polypharmacy? Usually described numerically as five or more prescribed medications at any time European Project AgeD in Home Care (ADHOC) uses 9 or more medications or Administration of more medications than clinically indicated Our Aging Population Chronic Diseases are on the rise Multiple Medications are often used to treat chronic illness Sharp rise in aging population 300% Rise in elderly disabled in North America by 2050 Average North American over the age of 60 years has 2.2 chronic diseases Our Aging Population Statistics Statistics Statistics Average elderly patient in community consumes 4 medications daily Average elderly patient in a nursing home consumes 7 medications on average Risk Factors Advanced Age 13% of US population Account for 33% of prescription and 40% on nonprescription use Female 57% of women greater than 65 years take at least 5 medications 12% take at least 10 Low Education Level Multiple Morbidities Average adult over 60 years has 2.2 chronic conditions Often based off of evidence based medicine Core Measures Depression Multiple Prescribers Frailty Risk Factors (Prescriber) Practice Environment Low number of listed patients High Workload Low rate of admission to hospital High practice prescribing rate High average number of prescribed medications Lower prevalence in female prescribers No association with age or duration of practice Risk Factors (Prescriber) Medical Guidelines Intended to support physicians in their drug choice Usually focus on one disease state Tend generate more drug therapy especially when compounded Examples: CHF, AMI, COPD Risk Factors (Prescriber) Prescribing Habits Dominate perception that diseases should be treated with drugs A visit to a provider should end with a prescription Can lead to a medical cascade of prescribing Risk Factors (Prescriber) Physician Behavior Failure to make a proper medical review Poor communication amongst prescribers Mistrust of guidelines that decrease medications use (Antibiotics) Risk Factors (Patient to Prescriber) Good interaction essential Reviews of entire medication list with provider is essential Personnel continuity Multiple providers and pharmacies increase the risk of polypharmacy Risk Polypharmacy Associated With Poor Adherence Inappropriate Prescribing Adverse Drug Reactions Drug Interactions Geriatric Syndromes Morbidity/Mortality Poor Adherence Nonfulfillment Prescribed but never filled Nonpersistence Patients decides to stop taking without being advised be health professional Nonconforming Incorrect Dosing Skipping Doses Incorrect times Inappropriate Prescribing The use of medications that introduce a greater risk of adverse drug-related events where a safer, as-effective, alternative therapy is available to treat the same condition. Includes Use of medicines at a higher frequency Longer then clinically necessary Drug-Drug Interactions Underuse of clinically relevant medications Adverse Reactions An unfavorable medical event related to medication misuse or Noxious or unintended response t medication despite appropriate drug dosage or prophylaxis, diagnosis or therapy of medical conditions Adverse Reactions 4.3 million ADR related health care visits in 2005 Occur in up to 35% of elderly patients in outpatient setting Account for 10% of ER visits Adverse Reactions Higher amount of meds, higher rate of ADRS 2 Meds 13% 5 Meds 58% 7 or more Meds 82% Adverse Reactions Most Common Classes Cardiovascular Diuretics Anticoagulants NSAIDs Antibiotics Hypoglycemic Drug Interactions Elderly at risk Comorbidities Nutritional Status Number of drug interactions increase as number of morbidities and medications increase Often more medications are added to treat these issues that further complicate problems Geriatric Syndromes Cognitive Impairments Medications implicated in up to 39% of cases Four or more medications added the day before a delirium episode is a risk factor Finnish Study on Cognitive Impairment No Polypharmacy – 22% risk Polypharmacy – 33% Risk Excessive Polypharmacy – 54% Risk Geriatric Syndromes Cognitive Impairments (cont) Delerium Opiods Benzodiazepines Anticholinergics Dementia Benzodiazepine Anticonvulsants Anticholinergics Tricyclic Antidepressants Geriatric Syndromes Falls Increase morbidity and mortality Cardiovascular, Psychotropic Urinary Incontinence Diuretics Psychotropics Opioids Sedatives Geriatric Syndromes Nutrition Associated with poorer nutritional status Decreased intake of soluble and nonsoluble fiber, fat soluble vitamins, B vitamins and minerals Increased intake of cholesterol, glucose and sodium Medications (Beers) Updated in 2012 Goal The goal of the 2012 AGS Beers Criteria is to improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs) Improving selection of drugs Evaluating patterns of drug use within population Educating on proper drug use Evaluating health-outcome, quality care, cost, and use data Medications (Beers) Three Categories Potentially inappropriate medications and classes to avoid in older patients potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes medications to be used with caution in older adults Beers Criteria for Potentially Inappropriate Use in Older Adults Medication/Class Rationale Anticholinergics(diphenhydramine, hydroxyzine, promethazine Clearance reduced, confusion, dry mouth, constipation. Diphenhydramine ok for acute allergic reaction Alpha1 blockers (doxazosin, prazosin, terazosin) High risk of orthostatic hypotension, alternative agents have superior risk/benefit profile Antiarrhythmic drugs (Class Ia, Ic, III) (amiodarone, dronaderone, sotalol) Rate control yields better balance of benefits than rhythm for most older pts Tricyclic Antidepressants (TCAs) (amitriptyline, doxepin >6mg/d, imipramine Sedation, orthostatic hypotension Antipsychotics, first (conventional)and second (atypical) generation (haloperidol, aripiprazole, olanzapine, risperidone, ziprasidone) Increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia Benzodiazepines (alprazolam, lorazepam, temazepam, clorazepate, chlordiazepoxide, diazepam, zolpidem (not quite a benzodiazepine) Increased sensitivity, delirium, cognitive impairment, falls. May still be appropriate for some in Beers Criteria for Potentially Inappropriate Use in Older Adults Medication/Class Rationale Insulin, Sliding Scale Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting Megestrol Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults Glyburide Greater risk of hypoglycemia in older patients Metoclopramide Avoid, unless for gastroparesis Meperidine Not an effective oral analgesic in dosages commonly used; may cause neurotoxicity; safer alternatives available Indomethacin, Ketorolac Increase risk of GI bleeding and PUD Carisoprodol, Cyclobenzaprine Poorly tolerated, sedation, questionable efficacy Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Syndrome Drug Rationale Heart Failure NSAIDs, COX-2 Inhibitors, Diltiazam, Verapramil, Pioglitazone, Rosiglitazone, Dronedarone Potential to promote fluid retention and exacerbate heart failure Syncope Doxazosin, Prazosin, Terazosin Increases risk of orthostatic hypotension Chronic seizures or epilepsy Bupropion, Olanzapine, Tramadol Lowers seizure threshold Delirium TCAs, Anticholinergics, Benzodiazepines, corticosteroids, meperidine, Avoid in patients with or at high risk for delirium Dementia and cognitive impairment Anticholinergis, Benzodiazipines, Zolpidem, Antipsychotics CNS effects. Anitpsychotics -Increase in stroke and mortality in persons with dementia History of falls or fractures Anticonvulsants,Antipsychotics Benzodiazepines, Zolpidem, TCAs and SSRIs Ability to produce ataxia, impaired psychomotor function, syncope, and additional falls; Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Syndrome Drug Rationale Parkinson’s disease All antipsychotics except for Quetiapine and Clozapine) Antiemetics-Metoclopramide Prochlorperazine, Promethazine Dopamine receptor antagonists with potential to worsen parkinsonian symptoms. History of gastric or duodenal ulcers Aspirin (>325 mg/d) Non–COX-2 selective NSAIDs May exacerbate existing May exacerbate existing ulcers or cause new or additional ulcers Urinary incontinence (all types) in women Estrogen oral and transdermal (excludes intravaginal estrogen) Aggravation of incontinence Lower urinary tract symptoms, benign prostatic hyperplasia Ipratropium, Tiotropium, Anticholinergics (except antimuscarinics for urinary incontinence) May decrease urinary flow and cause urinary retention Stress or mixed urinary incontinence Doxazosin, Prazosin, Terazosin Potentially Inappropriate Due to Drug–Disease or Drug–Syndrome Interactions That May Exacerbate the Disease or Syndrome Drug Rationale Recommendation Dabigatran Greater risk of bleeding than with warfarin in adults 75 or greater; lack o evidence for efficacy and safety in individuals with CrCl < 30 mL/min Use with caution in adults aged _75 or if CrCl < 30 mL/ min Antipsychotics, Carbamazepine, Mirtazapine, SSRIs, TCAs May exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia; need to monitor sodium level closely when starting or changing dosages in older adults due to increased risk Use with caution Preventions Barriers Clinician uncomfortable with changing or discontinuing Particularly medication prescribed by another clinician Little evidence based support on discontinuing medications Patients psychologically or physical dependant on medication Discontinuing medication perceived as inadequate care Prevention Barriers (cont) Potential harms such as adverse drug withdrawal events (ADWEs) Clinically significant symptoms or signs likely caused by medication cessation Cardiovascular and CNS classes most common Prevention Considerations Duration of each medication Is there still an indication for each medication Are indications consistent with current guidelines Adherence If patient well without taking, pointless to continue prescribing Prevention Prescribing cascade Discontinuing medication may reveal adverse effects of other therapies Very little evidence to guide withdrawal process for polypharmacy A gradual tapering is often recommended Prevention Clinical Controlled Trials Medication Reviews by pharmacist Prescriber Education Programs Academic detailing Comprehensive geriatric assessments Multidisciplinary interventions engaging prescribers and pharmacists Prevention Nurses Role Information Instruction Organization Prevention Information –Discuss with patients Keep an accurate list of medications Keep complete list of medical providers and contact information Post the name and telephone number of local pharmacy Prevention Instruction: Teach patients about Each medication, including name, appearance, purpose and effects Potential adverse effects and interactions of each medication Importance of contacting healthcare provider with concerns and questions Potential drug –related problems that warrant emergency care Prevention Instructions (continued) Importance of taking medications exactly as directed Importance of using only one pharmacy to obtain drugs Prevention Organization: To help manage drugs Avoid sharing medications Store medication in secure dry area away from sunlight Refrigerate if necessary Dispose of old medications properly Prevention No single approach extensively studied Prescribing and impact on outcomes inconsitent throughout studies Best approach is probable a combined approach Patient needs to be involved in the process Where Are We Now? Quebec 2004 March 2003 a rise of severe CDAD in Montreal and regions in Quebec1 12 Hospitals studied over 6 months in 2004 1719 cases reviewed Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associate diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9 Quebec 2004 Age Age (yrs) Cases No of Cases per 1000 admissions % Attributable 30-Day Mortality Rate <40 41-50 51-60 61-70 71-80 81-90 >90 76 85 181 272 523 458 114 3.5 11.2 20.0 24.4 38.3 54.4 74.4 2.6 1.2 3.2 5.1 6.2 10.2 14.0 Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9 Quebec 2004 Antibiotics Antibiotic Odds Ratio Any Cephalosporin 3.8 1st Generation 2.4 2nd Generation 6.0 3rd Generation 3.0 Any Fluoroquinolone 3.9 Ciprofloxacin 3.1 Gatifloxacin/Moxifloxacin 3.4 Levofloxacin 0.6 Clindamycin 1.6 Macrolides 1.3 Penicillin w/β-Lactamase Inh 1.2 Carbapenems 1.4 Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9 Quebec 2004 Attributed Mortality 6.9% A previous Canadian study 6 years prior had 1.5% mortality rate1 All hospitals had the similar dominant strain (129 of 157 isolates or 82%) Among the 38 patients who acquired CDAD in the community, 37% had NAP1/027 Isolates of dominant strain resistant to all quinolones but susceptible to clindamycin Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9 NAP1/027 Strain Linked to several outbreaks in Canada, Britain, US, and Netherlands. Has been around since 1984 Has become fluoroquinolone resistant since then Can produce 16 times more toxin A and 23 times more toxin B than standard strain Produces an extreme amount of spores Higher mortality and colectomies Has in many area become the dominate strain Possibly due to severe diarrhea Antibiotic trends Florida 1998-20031 Codes as C. diff on discharge 34/100,000 to 70.2/100,000 • Biggest change from 2000-2001 (35.0 to 46.9) Death among patients coded with C. Diff 94.8/1000 to 106.7/1000 • More than 80% of deaths were 75 or older Authors felt the NAP1/027 was a contributing factor Sanderson, R A, Bendixsen O, Increasing Clostridium difficile morbidity and mortality, Florida hospitals, 1998-2003, Abstract 2006 Conference on Antimicrobial Resistance Community-Acquired Definition controversial Many have been in a health care facility recently Local study showed that 79% of CDAD patients in hospital acquired if considering 30 day readmission criteria Young patients without a history of antibiotic use becoming more common Many have close contact with diarrheal CDAD1 NAP1/027 is out in the community 1Centers for Disease Control and Prevention. Severe Clostridium difficile-associated disease in populations previously at low risk—Four States, 2005. MMWR Morb Mortal Wkly Rep 2005;54:1201-5 Risk Factors (Hospitalized Patients) Increasing Age (excluding infancy) Younger population is becoming more at risk Severity of Underlying Disease Non-surgical gastrointestinal procedures Presence of nasograstric tubes Anti-ulcer medications ICU Stay Length of Hospital Stay Antibiotics Length of therapy Multiple Antibiotics Antibiotics Fluoroquinolones Originally considered a low risk Readily available, particularly ciprofloxacin Eliminates gram negative and anaerobic Full resistance to the newer NAP1/027 strain Appropriate use Use narrower spectrum where possible Minimize usage of “double coverage” Streamline antibiotics as soon as possible Minimize the use of agents that are largely excreted in the gut to minimize the selection of resistant gram negatives and destroy gut flora Minimize use of agents that have significant antianaerobic activity-spare gut anaerobes Shorten the length of therapy