Polypharmacy

Treating an adverse drug event as a new medical condition

Prescribing Cascade

Monitor med list, consider ADRs as a DDX, try to go with no meds

How can you avoid a prescribing cascade

5+ meds

Polypharm

choosing the best drug, determining dose and schedule for physiologic status, monitor effectiveness and toxicity, patient education, indications for seeking consultation

What is the process of prescribing a medication

absorption, distribution, metabolism, excretion (ADME)

Pharmokinetics includes

the physiologic effect of the drug (what the drug does to the body)

Pharmodynamics

Increased Vd (more fat), Decreased clearance (renal function), prolong t1/2, increased plasma concentration, decreased albumin (increased free), decreased 1st pass (increase serum concentraion)

Why do doses need to be handled with care when it comes to the elderly

all noxious and unintended responses to a medical product related to ANY dose (drug -> effect)

Adverse Drug Reaction (ADR)

Any untoward medical occurrence in a patient administered a medicinal product and which does NOT have to have a casual relationship with treatment

Adverse drug event (ADE)

Polypharmacy (MAJOR), physiological changes (ADME), cognitive impairment

Contributing factors to ADEs

36% (85% had one Rx, 38% used OTC)

In 2010 what percentage of community-dwelling adults were on 5+ prescription meds?

Ginkgo Biloba + warfarin = bleeding

St. John's Wart + SSRI = Serotonin Syndrome

What are some examples of Herbal medicines interacting with Prescription Meds - ASK YOUR PATIENTS ABOUT SUPPLEMENTS

Ginkgo biloba, St. John's wart, echinacea, ginseng, garlic, saw palmetto, kava, valerian root

What are the 8 most commonly used supplements?

Absorption (BUT topical meds aren't going to work as well - decreased skin vascularity) - balanced by decreased 1st pass

Which is the least affected ADME?

Lipophilic drugs spread better (more fat, less water -> longer elimination times and prolonged effect)

decreased albumin and A1AG (monitor highly bound drug concentration - warfarin, phenytoin)

How is distribution affected by aging?

Decreased CYP P450, Phase II is chilling

How is metabolism affected by aging?

GFR decreases with age

Starting dose should be based on Creatinine clearance (may not be super accurate due to loss of muscle mass)

How is excretion/elimination affected by aging?

Start Low and go SLOW

Tips for starting medications in the elderly

receptor affinity changes or number, post-receptor alterations, impairment of homeostatic mechanism

Elderly populations may have changes in pharmacodynamics due

BENZOs, opioids, warfarin, heparin

Examples of medications that old people are sensitive to

Beta agonist/antagonist

Examples of medications that old people are resistant to

Increased risk of ADEs, decreased physical and cognitive capability

Polypharmacy is associated with...

Decreased clearance associated with aging -> compounds risk of ADE

Drug-drug interaction risk increase

Independent risk for hip fractures (probs CNS active drugs)

Increases probability of Prescribing cascade

Can lead to adherence issues

Why are older adults especially impacted by polypharmacy?

Insulin and sulfonylureas -> hypoglycemia

Warfarin -> GI and brain bleeding

Digoxin -> impairment of cognition, heart block

Benzos -> falls

1st G Antihistamines -> Anticholinergic effects

Opioids -> Constipation, sedation, confusion, cardiorespiratory depression, seizures

Antipsychotics -> death, pneumonia,

Chemo -> myelosuppression, hepatotoxicity, cardiotoxicity

FQs -> Tendon rupture, hypoglycemia, arrhythmias, C. Diff, MG exacerbation

Nitrofurantoin -> pulmonary fibrosis, neuropathy, hepatotoxicity

TMP-SMX -> hyperkalemia, hypoglycemia, SJS/TEN

Selected High Risk Drugs

Indication?

Effectiveness of the med?

Correct dosage and practical directions

Drug-drug interactions?

Drug-disease interaction

Unnecessary duplication

Duration?

Least expensive

Tips for appropriate prescribing in the elderly

hospitalization, prescribing cascade, renal impairment

Types of ADEs

Antipsychotics -> extrapyramidal effects -> anti-parkinson

Cholinesterase inhibitors -> urinary incontinence -> treatment

Thiazide -> hyperuricemia -> gout treatment

NSAIDs -> increased BP -> treatment

CCB -> peripheral edema -> diurectic

Prescribing cascade examples

Antipsychotics ->

Cholinesterase inhibitors ->

Thiazide ->

NSAIDs ->

CCB ->

A patients life expectancy, time until benefit from medication, goals of care, treatment targets

4 criteria for help decide when to start or continue meds

Review current drug therapy, discontinue potentially unnecessary therapy (taper that shit), consider ADEs as a potential cause for any new symptoms, consider non pharm approaches (lifestyle mods), substitute safer alternatives, reduce the dose (lots of ADEs are dose related so use the lowest dose), use of beneficial therapies when indicated

A stepwise approach to review medications for older adults

1st gen antihistamines, antiparkinsonian agents, antimuscarinic agents, Antiemetics, muscle relaxants, 1st gen antipsychotics (and clozapine), TCAs

Medications with anticholinergic effects

list of meds that are potentially inappropriate for older patients, those that should be avoided, to be used with caution, DDIs, and drug dose adjustments based on kidney function

The Beers Criteria includes

NSAIDs

Which class of drugs has the highest risk of ADEs?

Screening tool of Older Person's Prescription (STOPP), FORTA (Fit FOR the age), Drug Burden Index (Anticholinergics only)

Other medication criteria sets

implies a sense of 1 sidedness where the patient is dealing with or adapting to a situation

Compliance

refers to the duration that a patient will continue with a medication treatment (doesn’t address the 24% of prescriptions that aren't filled)

Persistence

the extent to which a person's behavior (taking meds, following a diet, executing lifestyle changes) corresponds with agreed recommendations from a health care provider - estimated 50%

Adherence

Ask about medications, supplements, OTCs in different ways

Demonstrate inhaler/eye dropper/topical usage

Request that patient brings their medications

Explicitly inquire about missing does and difficulties with adherence

Decrease complexity of regimen

Tips for Assessing Medication Adherence

Peer relationships, pill organizers, calendars, schedule check ins, avoid barriers (cost, dysphagia), involve caregivers

What can increased compliance

Pill boxes, Apps, tablet splitters or crushers for homies with dysphagia, eyedrop guides,

What are some examples of Adherence Aids

Prescription Drug Plan (PDP) - each one has a distinct formulary, restrictions on prior auth, quantity limits, and step therapy

All medicare A/B participants are eligible to enroll in the

Those with multiple chronic disease states, expected to use $3000 worth of meds, are on multiple medications

Who is eligible for Medication therapy Management (MTM) as a part of Medicare Part D

Evaluation of medication regimen by Pharmacist or provider with a medication action plan and personal medicationlist- goal is to decreased ADEs and improve outcomes

What does an MTM consist of?

Assist in adherence and disease management

Federal mandated monthly drug regimen reviews in skilled nursing homes

Consultants in hospitals, PACE programs, etc

Counsel patients on all new prescriptions

Assist in designing proper regimens - Med Rec

What is the Pharmacist role in geriatric care