Polypharmacy and Deprescribing Flashcards
What is polypharmacy? What is it not?
High number of medications
AND
Medications that are not appropriate
What is the cut off of the number of medications for polypharmacy?
No universally agreed-upon cutoff
Literature supports 5 or more medications as being associated with ↑ risk
More than 10 medications - hyperpolypharmacy
What is hyperpolypharmacy?
More than 10 medications
Describe the lack of appropriateness of medications component of polypharamcy?
Medications with no indication
Use of inappropriate medications –> Often no longer an indication for the medication
Is polypharamcy always a negative outcome?
No - Not always a bad outcome
Easy to be on multiple meds and be appropriate
Is polypharmacy the only concern in geriatrics? If not, what is also a concern
Under-utilization of indicated therapies is also common in older adults
Focusing too much on what is “too many” medications may discourage initiation of new medications, even when warranted
Which medications are not commonly prescribed in geriatrics (under-utilized)?
Bisphosphonates for osteoporosis (common)
Anticoagulation for atrial fibrillation
Pain medications
COPD treatment
What question should a pharamciwst be asking when evaluating the appropriateness of drug therapy in geriatrics?
Shifit to:
IS the pt taking the right medications?
More concerned about treating everything appropriately rather than the number of medications
The task for the clinician is not to determine whether too many or too few medications are being taken, but to determine if the patient is taking the right medications.”
Describe the percentage of seniors in Canada and the number of medications via class?
58% age 65-74 taking 5+ medications
80% aged 85+ taking 5+ medications
85 and over age category that take the most medications
As we age, diagnosed with more conditions that requires more medications
How many disease states is a concern? Why?
3 or more current dx states is associated with adverse functional outcomes
3 or more chronic conditions, more likely to live with fragility
Why should pharmacists be concerned about polypharmacy?
Number 1 risk factor for adverse drug reactions = number of medications taken
Describe the rate of adverse drug reactions (ADRs) in geriatrics?
10-30% hospitalizations in older adults
65% considered preventable
Major problem in the geriatric population
Regarding ADR’s and polypharamcy, older adults are particularly vulnerable to:
Altered medication response
More comorbidities
–> Drug good for one condition runs the risk of worsening another
Altered homeostatic mechanisms
–> More susceptible to orthostatic hypotension but need to treat hypertension
Limited EBM (often not enrolled in clinical trials)
Who developed the BEER’s criteria? What was it initially used for?
Originally developed by Dr. Mark Beers in the early 90’s to assist clinicians with identifying Potentially Inappropriate Medications (PIMs) for LTC residents
What is the purpose of the BEER’s criteria? Is it a stationary document?
Medications generally considered to have risks > benefits
Revised and updated to include all adults > 65 years
Since 2012 it has been revised and updated by the American Geriatrics Society every 3 years
Most recent edition published in 2023
What are the different sections of the BEERS Criteria?
5 sections
1) Medications generally considered inappropriate for older adults (Table-2)
2) Medications inappropriate for older adults with certain medical conditions (Be familiar with – avoid in general public)
3) Medications to be used with caution in older adults
4) Clinically important drug-drug interactions to avoid
5) Medications to avoid or dose-adjust in renal impairment (no need to memorize)
Also includes a table on medications with strong anticholinergic effects
Beers Criteria: Table 2 refers to? Examples?
Medications generally considered inappropriate for older adults (Table-2)
Unfavorable risk/benefit profile + better alternatives available
E.g. first-generation antihistamines, warfarin
Beers Criteria: Table 3 refers to? Examples?
Medications inappropriate for older adults with certain medical conditions (Be familiar with – avoid in general public)
Drug-disease interactions
E.g. NSAIDs in HF, Non-DHP CCB in HF
Beers Criteria: Table 4? Examples?
Medications to be used with caution in older adults
Some evidence of potential harm, or increased monitoring required in older adults
E.g. dabigatran, prasugrel, ticagrelor (anti-coags, anti-platlets, SGLT2I (orthostatic hypotension and hypovolemia risk)
Warrant further questions/increased monitoring to make sure they are used appropriately
BEER’s Criteria: Table 5? Examples?
Clinically important drug-drug interactions to avoid
E.g. opioids + gabapentinoids or benzodiazepines
BEERS criteria: TAble 6? Examples?
Medications to avoid or dose-adjust in renal impairment (no need to memorize)
E.g. ciprofloxacin, baclofen, gabapentin, etc.
Older adults likely to have renal impairment
What are PIMs?
Potentially Inappropriate Medications
Describe the utility of the BEER’s List
Useful tool to assist in identifying PIMs for older adults
–> Identify medications that may warrant reevaluation or closer monitoring
What are some limitations of the BEER’s list?
Absence of a Beers medication does not mean an older adult’s medications are optimized
Most ADR-related hospitalizations in older adults are not due to Beers drugs
What are the two categories of resources that can be used to adress polypharmacy in older adults?
Explicit Prescribing Tools
Implicit Prescribing Tools
What are explicit prescribing tools? Pros and Cons? Examples?
Usually consensus criteria developed by a panel of experts
Lists of medications to either use or avoid
Pros: Easy to use and implement
Cons: Miss other types of DTPs
E.g. Beers Criteria, Stop-and-Start Criteria (Consensus in Ireland Used in UK and Europe)
What are implicit prescribing tools? Pros and Cons?
Outline a process for the clinician to follow to identify DTPs
Pros: Very comprehensive approach to identifying DTPs
Cons: Require clinician knowledge/expertise, time-consuming
Examples of explicit prescribing tools
Beers Criteria
STOPP/START Criteria
STOPP FRAIL
Implicit Prescribing Tools Examples
Medication Appropriateness Index
Good Palliative-Geriatric Practice Algorithm
What is the medication appropriateness index? When is it useful?
Can be used as a research tool to evaluate a patient’s medication regimen
More useful in clinical practice as a series of questions to ask in:
–> As part of a comprehensive medication review to assess the appropriateness of each drug
–> Before starting a new medication
What is the medication appropriateness index? Major Limitation?
What is a concern with the medication appropriateness index?
Does not help identify untreated conditions!
What is the Good Pallative-Geriatric Practice Algorithm? Why is it useful?
Originally developed in Israel to reduce polypharmacy in LTC residents
Over 1 year study:
Stopped an average of 2.8 medications/person in intervention group
Significant reductions in:
–> Hospitalizations (11.8% in intervention group vs. 30% in control group)
–> Mortality (21% in intervention group vs 45% in control group)
Good Palliative-Geriatric Practice Algorithm and limitation
What is a prescribing cascade?
Treating an adverse effect of a drug with another medication
What are some other resources to use to asses polypharmacy in older adults?
Geri-RxFiles
Deprescribingnetwork.ca
MedSafer | Working Towards Safer Prescribing
Describe Geri-Rx Files
Great resource for evaluating the appropriateness of drug therapy for a given condition in an older adult
Incorporates the Beers and STOPP criteria
Provides ALTERNATIVES to medications considered inappropriate
Define Deprescribing
Deprescribing = the process of tapering, reducing, or stopping medications to improve clinical outcomes
Describe the Canadian Deprescribing Network
Deprescribing guidelines developed for certain medications/conditions:
Developed patient information about the risks of certain medications:
Non-pharmacological measures for sleep
Also general deprescribing patient information
Time to benefit requires knowledge of:
What resources are helpful?
Clinical knowledge of medication and condition (acute symptoms or illnesses)
E.g. Acetaminophen for headache
E.g. Amoxicillin for otitis media
More challenging for preventive therapies
References e.g. RxFiles, Geri-RxFiles
Considerations for time to benefit:
Patient’s individual risk of event
–> Secondary prevention will have greater magnitude of benefit (lower NNT) than primary prevention
Clinical trial data
–> How long was the study?
–> When was impact of intervention seen?
What are some strategies for sucessful deprescribing?
Patient/caregiver buy-in is key!
Taper/stop one medication at a time if possible
- Start with medications causing problems
- Medications with no indication
- Potentially inappropriate medications, medications with risk > benefit
- Medications not in line with goals of care
Watch for/try to break up prescribing cascades
Consider whether any drug interactions may be unmasked when stopping a medication
E.g. stopping amiodarone in a patient stabilized on warfarin
E.g. stopping furosemide in a patient stabilized on lithium
Anticipate and manage potential adverse drug withdrawal reactions
What are adverse drug withdrawal reactions?
Clinically significant signs or symptoms on discontinuing a drug
Physiologic withdrawal
Recurrence of underlying condition
Discontinuation symptoms
How to manage adverse drug withdrawal reactions?
When in doubt, taper a medication off slowly
Particularly if on a higher dose and/or have been taking chronically
Advise on how to manage unpleasant symptoms during the tapering process
Tapering regimens for select medications: Geri-RxFiles
What are some drugs associated with adverse drug withdrawal reactions?
What are some medications not associated with drug withdrawal reactions?
Bisphosphonates and denosumab
Aspirin
Anticoagulants
Statins
Vitamin and mineral supplements
