Therapeutics and polypharmacy (1) Flashcards
(2) types of contraindications for the drug use (in general)
- Relative contraindication → caution should be used when two drugs or procedures are used together. (It is acceptable to do so if the benefits outweigh the risk.)
- Absolute contraindication → event or substance could cause a life-threatening situation
What’s ‘Shared Care Agreement’?
Shared care → where a GP supports and prescribes treatment for a patient which was initiated by a specialist.
- patient continues to be followed-up in reviews by the specialist
- a clear plan of care and defined protocol, medication specific, with a statement of monitoring arrangements, and responsibilities of the specialist, GP and patient
- GP can decide not to share care if they feel they can’t accept the responsibility, are not competent etc
What’s polypharmacy?
- taking multiple medications concurrently to manage co-existing health problems
- use of >4-5 medications per day or taking more medications than clinically required
How often should we review meds of 75 y old patient?
- at least annually
- 6/12 if taking ≥4 meds
Who can perform meds review?
Clinical pharmacist, doctor, PA, (for some drugs) nurse practitioner/nurse prescribers
What’s NO TEARS?
NO TEARS – mnemonic to maximise 10 minute consultations for med review
What’s ‘N’ in NO TEARS?
Need and indication
- Does the patient know why they take each drug?
- Is each drug still needed? Was long term therapy intended?
- Is the diagnosis refuted? (cancelled/changed)
- Is the dose appropriate? Would non-pharmacological treatments be better?
What’s ‘O’ in NO TEARS?
Open questions
- Allows patients to express views
- Helps to reveal any problems they may have
What’s ‘T’ in NO TEARS?
Test and Monitoring
- Assess disease control. Any conditions under-treated?
- Use appropriate reference for monitoring advice e.g. BNF, Shared care
- protocols, NPHS Wales monitoring guidelines
What’s ‘E’ in NO TEARS?
Evidence and Guidelines
- Has the evidence base changed since initiating drug?
- Are any drugs now deemed ‘less suitable’?
- Is dose appropriate? (Over or under-treatment, extreme old age)
- Are other investigations now advised e.g. echocardiography?
What’s ‘A’ in NO TEARS ?
Adverse Events
- Any side effects?
- Any OTC or complementary medicines?
- Check interaction, duplications or contra-indications.
Don’t misinterpret an adverse reaction as a new medical condition
What’s ‘R’ in NO TEARS?
Risk Reduction or Prevention
•Opportunistic screening and risk reduction – are drugs optimized to reduce the risks?
What’s ‘S’ in NO TEARS?
Simplification and Switches
Can treatment be simplified?
Explain any cost effective switches
What should we think of (during meds review) if pt uses PPI? (2)
Can they be stopped/reduced?
- increased risk of GI infection
- risk of fractures in high dose/prolonged use
What should we think of (during meds review) if pt uses quinine?
Can this be stopped? MHRA advice
Adverse effects: retinopathy, thrombocytopenia, tinnitus, lichen planus etc.
What should we think of (during meds review) in a patient who is on hypnotics/benzos?
Can we stop it?
Adverse effects: falls, addiction
Metoclopramide
- class
- SEs
Metoclopramide
*should be used only short-term
Class: D2 receptor antagonist
SEs:
- extrapyramidal effects: oculogyric crisis (particularly a problem in children and young adults)
- hyperprolactinaemia
- tardive dyskinesia
- parkinsonism
- Metoclopramide should be avoided in bowel obstruction, but may be helpful in paralytic ileus.
How should we use antihistamines and why?
Short - term only
Example: chlorpheniramine
- sedating
- antimuscarinic properties (e.g. urinary retention, dry mouth)
Alpha-blocker in men on med review - what should we think of?
Consider stopping in men with long-term care
Use: management of benign prostatic hyperplasia and hypertension
Examples: doxazosin and tamsulosin
Side-effects:
- postural hypotension
- drowsiness
- dyspnoea
- cough
When should we stop bisphosphonates?
If the treatment is > 5 years long
Cumulative GI risk in the following (3) drugs
- SSRI
- NSAID
- aspirin
What to check with Digoxin?
- U+E
- GFR
Consider stopping if ↓ eGFR
Consideration for metformin (when to stop)
- Check renal function
- Reduce dose/stop if reduced eGFR
What class of drug do we consider stopping in pt with dementia?
Consider reducing/stopping antipsychotics
What class of drugs is better tolerated for use in depression in pt with dementia?
SSRI
What classes of drugs can express anticholinergic effects?
- H2RA
- TCA
- Antihistamines
List the drugs that may be associated with rapid symptomatic worsening/ withdrawal symptoms if stopped → require cautious and stepwise withdrawal
- ACE inhibitors in HF (left ventricular impairment)
- Diuretics in HF
- Drugs for HR or rhythm control (Digoxin, b-blockers)
- opioids
- anti-depressants
- antipsychotics
- antiepileptics
- Clonidine (alpha agonist → to treat HTN)
- Baclofen
- corticosteroids
- benzodiazepines
What drugs to withhold if a patient is severely dehydrated?
*severly means more than a pt suffering from minor D/V
- ACE inhibitors/ Angiotensin Receptor Blockers
- NSAIDs
- Diuretics
- Metformin
* drugs can be restarted again when pt has improved
* pt with advanced HF can decompensate rapidly when off drugs → specialist advice is needed
Drugs in which specialist advice is advised before altering
- anti-convulsants for epilepsy
- anti-depressants, anti-psychotics, mood stabilising (e.g. Lithium)
- drugs for management of Parkinson’s disease
- Amiodarone
- DMARDs, anti-rheumatic drugs
Combinations of NSAIDs +… drugs or diseases that are classified as high risk
These combinations of NSAIDs +… should be avoid where possible
NSAIDs + … :
- ACE inhibitors or Angiotensin receptor blockers + diuretics
- in existing renal disease
- diagnosis of HF
- warfarin
- age 75+ and no PPI cover
Which combinations of drugs Warfarin +… should be avoided?
We should avoid combination of Warfarin +… :
- another antiplatelet
- NSAIDs
- Macrolides
- Metronidazole
- azole anti-fungals
What (3) drug classes to avoid in HF diagnosis
- TCAs
- NSAIDs
- Glitazone
