Polypharmacy Flashcards
Direct Acting Oral Anticoagulants (DOACs)
Examples:
Apixiban
Rivaroxaban
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
Thyroxine (levothryoxine)
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
Levodopa and dopa-decarboxylase inhibitors
(Co-careldopa)
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
Statins
Examples:
Simvastatin, artorvastatin
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
Combo-inhaler: LABA + LAMA
Examples:
LABA – salmeterol, formoterol
LAMA – tiotropium, glycopyrronium
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
Anti-muscarinics
Example: Solifenacin
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
Calcium channel blockers
Examples:
Amlodipine
Felodipine
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
Proton pump inhibitors (PPIs):
omeprazole, lansoprazole
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
Metformin:
Proton pump inhibitors (PPIs):
omeprazole, lansoprazole
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
Sertraline
Drug (class)
Primary mechanism of action
Drug target
Main side effects
Extra information
The seven steps:
What’s the patients problem?
irregular heart rate, fatigue, constipation, nausea
- Dehydration
- Hypothyroidism not managed sufficiently
- Drug side effects
- Potential drug interactions
Therapeutic objectives
- Decrease number of medications if valid
- Find cause and manage symptoms
- Reduce amlodipine as BP well below target
- Review medication and adjust doses
- Look at current BP and glycemic index and see if this is appropriate for his age. Above 85 BP of 130 is normal, need BP under control as worried of cardiovascular risk but falls in elderly is biggest mortality so we worry more about hypotension, so higher target is fine as we are worried about falls in older people. Also hypoglycaemia has same thing, we worry about hypos as much as hyperglycaemia associated with diabetes
Explain the mechanism of action of Apixiban as a treatment for atrial fibrillation.
- Target for apixiban is factor Xa, which is an enzyme released by the liver. It is an Xa inhibitor
- Location-In the bloodstream and platelet cell surface, monocytes and endothelial cells
- Stops thrombin activation and reduces risk of clots so associated with treatment of AF to reduce stroke risk
Which of Mr Fitzpatrick’s problems may be caused by apixaban? (https://bnf.nice.org.uk/drug/apixaban.html)
Which other symptoms might be related to his prescriptions?
- Apixaban-nausea, unusual but could get iron deficiency anaemia as you are more likely to bleed from any ulcer you have etc.
- Metformin-nausea
- Thyroxine-headache
- Amlodipine-headache
- Atorvastatin-constipation, nausea, light headedness
- Omeprazole-constipation, headache, light headed
Which drugs should not be stopped?
As a general guide:
- The indication may have expired
- Risk/benefit no longer appropriate
- Medicine combination is hazardous due to interactions
- Pill burden too great for patient, which can lead to poor adherence to the important drugs
Which drugs could potentially be stopped?
As a general guide:
- The indication may have expired
- Risk/benefit no longer appropriate
- Medicine combination is hazardous due to interactions
- Pill burden too great for patient, which can lead to poor adherence to the important drugs
Do not stop thyroxine and apixaban
Which drugs should not be stopped?
- Thyroxine-replacing a molecule your body is no longer producing
- Apixaban-chadvasc score (this is specifically used for AF, whereas Q score is used more generally for cardiac risk). His risk is about 5% per year but it will reduce it to about 1% per year.
Which drugs could potentially be stopped?
- High Q risk driven by age, not BP which is very good for his age. Increasing BP to 140 only increases Q score by a very small amount and lets say amlodipine is causing his light headedness then this puts him at risk of falls. So good argument to stop amlodipine and allow BP to raise a bit.
- Statins-stop because these could be contributing to side effects. Don’t know how good they are for older people. Personally would keep him on this because he is at high risk and unlikely to be causing worse symptoms
- Metformin-very good HbA1c and also he is 82 so don’t need to worry about long term microvascular complications like you would in a younger person with diabetes.
- Omeprazole-hard to stop as get a rebound, commonly overprescribed. Meant to only be short term anyway.
- Omeprazole
- Metformin
- Atorvastatin
- Amlodipine
-Explain that they can try stopping it because it may help reduce symptoms eg headache and light headedness. Also their blood pressure is currently well controlled so they might not require it. We can try stopping it and monitor blood pressure at the same time
Why do we have this problem of polypharmacy?
- Ageing population with more diseases that need chronic treatment
- 30 years ago we would have accepted high blood pressure but now our targets have lowered which means more drugs
- Prescribing cascade-so start aspirin, worry about stomach lining so give omeprazole which causes side effects so go on more drugs etc.
- All our guidelines for each drug are written separately doesn’t taken into consideration the fact that we would likely have more diseases if have one
Common reasons for unnecessary drugs:
- Drs aren’t good at prescribing conservative measures-bad at educating patients. Just start them on drugs.
- problem may have been resolved and drug may stay forever. Once saw someone who had high potassium and magensium and the reason was that they had been prescribed ace inhibitor and given potassium and magesium which were needed but now not.
Why is polypharmacy important?
-The more drugs you taken, the higher the risk of interaction.
- Constipation, tired, dizzy, itchy eyes
Solifenacin-M3 receptor in bladder
Stops contraction of bladder so problems of overactive bladder
Learn this slide!
Saliva produced is parasympathetic effect so get dry mouth due to blocking parasympathetic effect
What should not be stopped?
COPD and parkinsons-influence of QOL
What drugs could be potentially be stopped?
COPD and parkinsons-influence of QOL
Sertraline – Reasons to continue
Medication may be maintaining her stable mood
Patient may think the medication is maintaining her stable mood
Patient may fear rebound of low mood
Sertraline – Reasons to stop
Contributing to to current symptoms
May not be needed at all if mood is managed
Increasing pill burden
Solifenacin – Reasons to continue
Medication may be managing her urinary symptoms
Patient may not want to change something which is working
Another tablet may not work as well for her
May have tried lifestyle measures previously which did not work
Solifenacin – Reasons to stop
Contributing to to current symptoms
Increasing pill burden
Tools for polypharmacy:
