Polypharmacy and Deprescribing Flashcards
What is polypharmacy? (2 - 3+2)
- High number of meds
- No universally agreed-upon cutoff
- Literature supports 5 or more meds as being associated with increased risk
- More than 10 meds = hyperpolypharmacy - Lack of appropriateness of meds
- Meds with no indication
- Use of inappropriate meds
True or False? Under-utilization of meds is never an issue in older adults
False - common in older adults
List some meds/conditions that are not prescribed (under-utilization) (4)
- Bisphosphonates for osteoporosis
- Anticoagulation for afib
- Pain meds
- COPD treatment
The task for the clinician is not to determine whether too many or too few meds are being taken, but to determine if the patient is taking the _____ meds
right
__% age 65-74 taking 5+ meds
__% age 85+ taking 5+ meds
58
80
Why are older adults using such a disproportionate amount of meds?
They tend to be a population that has 2 to 4+ chronic conditions which require meds
Why should we be concerned about polypharmcy?
Number 1 risk factor for adverse drug reactions = number of medications taken
Adverse drug reactions account for __-__% of hospitalization in older adults. Of which __% are considered preventable
10-30
65
Older adults are particularly vulnerable to polypharmacy and ADRs because? (4)
- Altered medication response
- More comorbidities
- Altered homeostatic mechanisms
- Limited EBM
What are the 3 sections of the BEERS criteria that we should know?
- Medications generally considered inappropriate for older adults
- Unfavorable risk/benefit profile + better alternatives available
- e.g., first-gen antihistamines, 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 in older adults
- E.g., dabigatran, prasugrel, ticagrelor
What is the utility of the BEERS criteria?
Useful tool to assist in identifying PIMs for older adults
- Identify medications that may warrant reevaluation or closer monitoring
While the BEERS criteria is a useful tool, what should we be aware of when optimizing medications? (2)
- 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 top 10 drug classes most commonly associated with seniors’ ADR-related hospitalizations?
- Anticoagulants
- Other antineoplastic drugs
- Opioids and related analgesics
- Glucocorticoids and synthetic analogues
- Beta-adrenoreceptor antagonists, not elsewhere classified
- NSAIDs (excluding salicylates)
- Loop (high-ceiling) diuretics
- Benzothiadiazine derivatives
- Other diuretics
- ACEis
What are explicit prescribing tools? (2)
What are the pros and cons?
- 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
What are implicit prescribing tools?
What are the 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
Give 3 examples of explicit prescribing tools
- BEERS criteria
- STOPP/START criteria
- STOPP FRAIL
Give 2 examples of implicit prescribing tools
- Medication Appropriateness Index
- Good Palliative-Geriatric Practice Algorithm
What is the Medication Appropriateness Index?
- 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
- As part of a comprehensive medication review to assess the appropriateness of each drug
- Before starting a new medication
What is the problem with the Medication Appropriateness Index and the Good Palliative-Geriatric Practice Algorithm?
They do not help identify untreated conditions
What is deprescribing?
The process of tapering, reducing, or stopping medications to improve clinical outcomes
What are some common meds that have deprescribing guidelines associated with them? (4)
- PPIs
- BZDs and Z-drugs for insomnia
- Cholinesterase inhibitors for dementia
- Glyburide and other hypoglycemics
The Canadian Deprescribing Network is developed patient information about the risks of certain medications. Such as? (7)
- NSAIDS
- Antipsychotics
- First-generation antihistamines
- Sulfonylureas like glyburide
- Opioids for chronic non-cancer pain
- Sleeping pills and anti-anxiety medications
- PPIs
What are the 5 steps you should be going through when approaching polypharmacy?
- Identify patients at risk of/experiencing polypharmacy or adverse drug reactions
- Obtain an accurate medication history
- Evaluate adherence to medications - Are any symptoms or problems the patient is experiencing potentially caused or worsened by a drug they are taking?
- Need to know medication’s pharmacology and side effects
- Also need to consider the time of onset of symptoms in relation to starting the drug - Match medical conditions with medications
- Align drug therapies with the patient’s goals and priorities
- Life expectancy
- Time to benefit of the med
- Pt preferences
What is time to benefit activity? (3)
- Refers to how long someone needs to take or be on a med before they’re likely to receive the anticipated benefit from it.
- Helps us evaluate appropriateness of different therapies within the context of how likely a particular patient is to receive benefit
- Geriatric meds towards people who are older and frailer
What are 2 considerations for determining 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 tips for successful deprescribing? (5)
- Patient/caregiver buy-in is key
- Taper/stop one medication at a time if possible
- Watch for/try to break up prescribing cascades
- Consider whether any drug interactions may be unmasked when stopping a medication
- Anticipate and manage potential adverse drug withdrawal reactions
What are adverse drug withdrawal reactions? (3)
Clinically significant signs or symptoms on discontinuing a drug
1. Physiologic withdrawal
2. Recurrence of underlying condition
3. Discontinuation symptoms
When in doubt (for an ADWR) what should be done?
Taper a medication off slowly - particularly if on a higher dose and/or have been taking chronically
What are the acute ADWRs seen with antidepressants (SSRIs, SNRIs, TCAs)? (4)
- Insomnia
- Agitation
- Sweating
- Malaise
What is the chronic ADWRs seen with antideprssants?
Depression recurrence
What are the ADWRs seen with hypnotics (BZDs, zopiclone, zalepon) (4)
- Rebound insomnia
- Agitation
- Anxiety
- Tremor
What are the ADWRs seen with narcotics? (6)
- Increased pain
- Mobility changes
- Insomnia
- Agitation
- Anxiety
- Diarrhea
What are the ADWRs seen with antipyschotics? (4)
- Hallucinations
- Restlessness
- Agitation
- Insomnia
What are the ADWRs seen with beta-blockers? (3)
- Increased HR
- Increased BP
- Angina
What are the ADWRs seen with digoxin? (2)
- Palpitations
- Increased HR
What are the ADWRs seen with diuretics (furosemide, HCTZ)? (4)
- Increased BP
- Edema
- Weight gain
- SOB
What are the ADWRs seen with PPIs/H2RAs? (3)
- Nausea
- Weakness
- Decreased BP
What are the ADWRs seen with corticosteroids? (3)
- Nausea
- Weakness
- Decreased BP
What are the ADWRs seen with anticholinergic agents? (5)
- Anxiety
- Nausea
- Vomiting
- Diarrhea
- Dizziness
What are the ADWRs seen with antiparkinsonian agents? (3)
- Rigidity
- Tremor
- Hypotension
What are some medications to know that are NOT associated with ADWRs? (5)
- Bisphosphonates and denosumab
- Aspirin
- Anticoagulants
- Statins
- Vitamin and mineral supplements
