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PHAR350 > Polypharmacy and Deprescribing > Flashcards

Polypharmacy and Deprescribing Flashcards

1
Q

What is polypharmacy?

A

high number of medications
-no universally agreed upon cutoff
-literature supports 5 or more medications as being associated with increased risk
-more than 10 medications: hyperpolypharmacy
lack of appropriateness of medications
-medications with no indication
-use of inappropriate medications

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2
Q

Is polypharmacy always a bad thing?

A

no
-ex: post-MI, HF, COPD, afib, diabetes, osteoporosis

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3
Q

What is the issue with focusing too much on polypharmacy?

A

under-utilization of indicated therapies is common in older adults
-anticoagulation for afib
-bisphosphonates for osteoporosis
-pain medications
-COPD tx
focusing too much on what is “too many” may discourage initiation of new medications, even when warranted

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4
Q

Why should we be concerned about polypharmacy?

A

1 risk factor for ADRs = number of medications

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5
Q

What percentages of hospitalizations in older adults do ADRs account for?

A

10-30%
-65% considered preventable

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6
Q

Why are older adults particularly more vulnerable to polypharmacy and ADRs?

A

altered medication response (PD and PK changes)
more comorbidities
altered homeostatic mechanisms
limited EBM

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7
Q

How much was spent on seniors hospitalized for ADRs in 2016?

A

$35.7 million

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8
Q

What is the BEERS criteria?

A

assists clinicals with identifying potentially inappropriate medications (PIMs) in adults > 65 yrs
-medications generally considered to have risks > benefits

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9
Q

What are the 5 sections of the BEERS criteria?

A

medications considered inappropriate in older adults
-unfavorable risk/benefit profile + better alternatives available
-e.g. 1st gen AH, warfarin
medications inappropriate for older adults with certain medical conditions
-drug-disease interactions
-e.g. NSAIDs in HF
medications to be used with caution in older adults
-some evidence of potential harm, or increased monitoring required
-e.g. dabigatran, prasugrel, ticagrelor
clinically important DDI to avoid
-e.g. opioid + benzo or gabapentinoid
medications to avoid or dose-adjust in renal impairment
-e.g. ciprofloxacin, baclofen, gabapentin, etc.

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10
Q

Describe the utility of the BEERS list.

A

useful tool to assist in identifying PIMs for older adults
-identify medications that may warrant re-evaluation or closer monitoring
however:
-absence of a BEERS drug does not mean an older adults medications are optimized
-most ADR-related hospitalizations in older adults are not due to BEERS drugs

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11
Q

Differentiate explicit and implicit prescribing tools.

A

explicit: lists of medications to use or avoid
implicit: outline a process for the clinician to follow to identify DTPs

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12
Q

What are the pros and cons of explicit prescribing tools?

A

pros: easy to use and implement
cons: miss other types of DTPs

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13
Q

What are the pros and cons of implicit prescribing tools?

A

pros: very comprehensive approach to identifying DTPs
cons: require clinician knowledge/expertise, time-consuming

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14
Q

What are examples of explicit prescribing tools?

A

BEERS Critiera
STOPP/START Critiera
STOPP FRAIL

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15
Q

What are examples of implicit prescribing tools?

A

Medication Appropriateness Index
Good Palliative-Geriatric Practice Algorithm

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16
Q

Describe the Medication Appropriateness Index.

A

can be used as a research tool to evaluate a patients medication regimen
more useful in clinical practice as a series of questions to ask
-as part of a medication review to assess the appropriateness of each drug
-before starting a new medication

17
Q

What is the downside of the Medication Appropriateness Index?

A

does not help identify untreated conditions

18
Q

Describe the Good Palliative-Geriatric Practice Algorithm.

A

originally developed in Israel to reduce polypharmacy in LTC residents
over 1 year study:
-stopped an avg of 2.8 meds/person in intervention group
-significant reductions in hospitalizations and mortality

19
Q

What is the downside of the Good Palliative-Geriatric Practice Algorithm?

A

does not help identify untreated conditions

20
Q

What is deprescribing?

A

the process of tapering, reducing, or stopping medications to improve clinical outcomes

21
Q

Describe a stepwise approach to managing polypharmacy.

A
  1. identify patients at risk of/experiencing polypharmacy or ADRs
  2. obtain an accurate medication history (evaluate adherence)
  3. are any sx or problems the pt is experiencing potentially caused or worsened by a drug they are taking? (know drugs pharmacology and AEs, consider time of onset in relation to time of starting drug)
  4. match medical conditions with medications (medications without indications, untreated conditions, therapeutic duplication, screen for PIMs, break prescribing cascades, optimize therapy, minimize pill burden)
  5. align drug therapies with the patients goals and priorities (life expectancy, time to benefit, patient preferences)
22
Q

How do you determine time to benefit?

A

clinical knowledge of medications and conditions
-acute drugs remain appropriate until the end of life
-more challenging for preventive therapies

23
Q

What are some considerations to think of when trying to determine time to benefit for chronic therapies?

A

patients individual risk of event
-secondary prevention will have greater magnitude of benefit than primary prevention
clinical trial data
-how long was the study?
-when was the impact of intervention seen?

24
Q

What are some tips for successful deprescribing?

A

patient/caregiver buy-in is key
taper/stop one medication at a time
-start with meds causing problems
-meds with no indication
-potentially inappropriate medications, risk > benefit
-medications not in line with goals of care
watch for/try break up prescribing cascades
consider if any DDI will be unmasked when stopping a med
anticipate and manage potential adverse drug withdrawal reactions

25
Q

What is an adverse drug withdrawal reaction?

A

clinically significant signs or symptoms on discontinuing a drug
-physiologic withdrawal
-recurrence of underlying condition
-discontinuation symptoms

26
Q

When in doubt about how to stop a drug, what is the best way to stop it?

A

taper off slowly
-particularly if on higher dose and/or have been taking chronically

27
Q

What are some drugs associated with withdrawal reactions?

A

antidepressants
hypnotics (BZD, Z-drugs)
narcotics
antipsychotics
beta-blockers
digoxin
diuretics
PPIs, H2RAs
corticosteroids
anticholinergics
antiparkinsonians

28
Q

What are some drugs that are not associated with withdrawal reactions?

A

bisphosphonates and denosumab
aspirin
anticoagulants
statins
vitamin and mineral supplements

PHAR350 (16 decks)

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