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10/10/2016
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MEDICARE CARE DELIVERY
Polypharmacy and Deprescribingin Older Adults
Oregon Geriatrics SocietyOctober 9, 2016
Arthur Hayward, MD, MBA
Internist and Geriatrician, Kaiser Permanente Northwest
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.2 October 10, 2016
Session Objectives
1. Identify examples of polypharmacy
2. Recognize the particular risks of polypharmacy in the elderly
3. Apply deprescribing algorithms
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.3 October 10, 2016
Case Histories
1. 45 yo ♂♂♂♂ on opioids for chronic pancreatitis reports his wife died unexpectedly.
2. 80 yo retired ♂♂♂♂ math teacher with dementia has become a “zombie” after entering a nursing home.
3. 74 yo ♀♀♀♀diabetic in ED for falls has HGBA1C of 6%.
4. Wife says her 79 yo mate won’t take all his medicines.
MEDICARE CARE DELIVERY
William Osler, 1849 - 1919
“Man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs. The desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures.”
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.5 October 10, 2016
Brief History of Polypharmacy
Drugs perform miracles
Drugs are widely prescribed
Drugs are too widely prescribed
Harms result
Deprescribing reduces polypharmacy
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.6 October 10, 2016
Outline
1. Signs of polypharmacy2. Altered risk/benefit in older adults3. Solution: Deprescribe?4. Signs of the deprescribing era 5. Benefits of deprescribing
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.7 October 10, 2016
1. Signs of polypharmacy
� Reflex prescribing
� Pharmaceutical hype
� Increased volume, costs, ADEs
� Backlash
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.8 October 10, 2016
� Failure to consider alternatives� Misapplying guidelines� Mistaking ADEs for new conditions
Reflex Prescribing
Huseyin Naci, John P A Ioannidis. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5577
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Non-pharma treatment alternativesFor… A. Not… B. But…
Back pain NSAIDs Cold and hot compresses
Insomnia Zolpidem Sleep hygiene
Urinary urgency Ditropan Pelvic floor exercises
Depression SSRI’s Cognitive behavioral Rx
Dementia “behaviors” Antipsychotics Environmental change
Anxiety Benzo’s Stress reduction activity
Adapted from KP Colorado Clinical Practice Guideline “Polypharmacy in the Elderly”
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.10 October 10, 2016
Statin use in adults older than 79
August 24, 2015. doi:10.1001/jamainternmed.2015.4302
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The Drug Cascade
Oxybutynin
Hip fracture
Fall
Orthostasis
Hip pain
Ibuprofen
HTN
HCTZ
Urinary Retention
Terazosin
A vicious Drug-ADE Cycle
Start here
Rochon P, Gurwitz J. Optimising drug treatment for elderly people: the prescribing cascade. BMJ, 1997;
315:1096-9
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.13 October 10, 2016
Pharmaceutical hype
�Product promotion
�Choice of product
�Narcotic epidemic
“Who is responsible for the pain pill epidemic?” in The New Yorker 11/8/2013.
Inducements
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
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Date of download: 8/2/2016Copyright © 2016 American Medical
Association. All rights reserved.
From: Pharmaceutical Industry–Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries
JAMA Intern Med. 2016;176(8):1114-10. doi:10.1001/jamainternmed.2016.2765
Target branded drugs
as a percentage of all
filled prescriptions in
the drug class.
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.16 October 10, 2016
Opioid (over)use
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Narcotic drugs more lethal than autos
New York Times, December 18, 2015
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.18 October 10, 2016
Pharma Promotion of Opioid Use
� Opioids have been aggressively and misleadingly marketed to physicians1
� Federal bodies and state medical boards received funds to promote pain relief 2
� Experts with pharma connections have rallied to criticize CDC proposed guidelines3
1 Van Zee A. The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health 2009;99:221-2272“Who is responsible for the pain pill epidemic?” in The New Yorker 11/8/2013. 3 AP wire services 1/31/2016 report on Interagency Pain Research Coordinating Committee
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� Deaths from prescription drug overdose have quadrupled since 2000.
� Opioids can worsen pain and functioning.
� Risks increase with dose increases.
� Use of heroin and illicitly produced Fentanyl has increased.
� CDC recommends non-pharmacologic approaches.
CDC assessment of opioid use
CDC Guideline with comment NEJM March 15, 2016 DOI: 10.1056/NEJMp1515917CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep 2016;65(RR-1:1-49
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.20 October 10, 2016
Volume
IMS Health Inc. data cited by Henry Kaiser Family Foundation“Drugmakers…” article. Wall Street Journal. Oct 3, 2016
• Increased numbers of prescriptions (4 B/y)
• Increased ADEs• Increased drug costs
($259B) ($329.1B)
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% of US adults reporting use of any and of > 5 drugs per day during preceding 30 days by age
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
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NHANES data reported by Kantor, E, et al. JAMA November 3, 2015 Volume 314, Number 17
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
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Data from the National Social Life, Health and Aging Project. College of Pharmacy, U of Chicago. JAMA Intern Med. doi:10.1001/jamainternmed.2015.8581 Published online March 21, 2016.
Findings:• Use of any med 84.1 � 87.7%• Use of >/= 5 meds 30.6 � 35.8%• Use of dietary supplements 51.8 � 63.7%• Risk of potential major drug-drug interaction 8.4 �15.1%
National Social Life, Health and Aging Project
Changes in Use of Drugs, OTCs, and Supplements 2005 to 2011
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Robin Hood Profiteering
The New Yorker January 4, 2016
How does epinephrine become a $1B drug?
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.24 October 10, 2016
Sunday Business SectionNew York TimesSeptember 4, 2016
Heather Bresch, Chief Executive, Mylan Pharmaceuticals
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The “Other” Drug Problem
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.25 October 10, 2016
The OregonianLIVING HEALTHLIVING HEALTHLIVING HEALTHLIVING HEALTH
Friday, Sept. 9, 2016
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.26 October 10, 2016
Signs of polypharmacy
Consumer mistrust and backlash
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.27 October 10, 2016
2. Risk/Benefit increases in adults >/= 65
� Changes in metabolism and pharmacokinetics/dynamics
� More conditions/ more guidelines/ more prescribers
� More side effects1 / “drug cascade” to treat side effects
� Less time to benefit
� Expense of polypharmacy (estimated ~ $50B/y in US)2
� Multiple meds: inconvenience, burden, misery
1. Patterson SM, Cadogan CA, Kerse N, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014;10:CD008165.2. CMMS estimate cited in Lyles A, Culver N, Ivester J, Potter T. effects of health literacy and polypharmacy on medication adherence. Consult Pharm. 2013;28:793-799.
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.28 October 10, 2016
3. Solution: Deprescribe?
� Pharmacists play a leading role.
� Deprescribing algorithms exist1,2,3
Deprescribing is the process of tapering or
stopping drugs, aimed at minimizing
polypharmacy and improving patient
outcomes.1-- Ian Scott, et al, Brisbane, Australia
1. JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324 Published online March 23, 2015.2. Garfinkle. Arch Intern Med. 2010;170(18):1648-1654.
3. Frankenthal, et al. (STOPP/START) J Am Geriatr Soc 62:1658–1665, 2014.
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Survey results of PCPs:
• Lack of knowledge (39% not aware tight glucose control harms older adults)
• Fear of bad report card (42%)
• Fear of legal liability (25%)
• Not enough time to discuss (30%)
JAMA Intern Med. 2015;175(12):1994-1996. doi:10.1001/jamainternmed.2015.5950
Barriers to Deprescribing
Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults
Garfinkel D, Mangin DArch Intern Med. 2010;170(18):1648-1654
Protocol- indicated stop of 311 meds in 64 of 70 patients included
Result
Failure (re-started for original indication) 2%
Success (consented and not re-started) 81%
Compared to matched cohort
Global improvement in health 88%
Mortality benefit 14%
LESS IS MORE
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.31 October 10, 2016
Improving drug therapy in elderly patients--the Good Palliative-Geriatric Practice algorithm
Garfinkel D, Mangin D. Arch Intern Med 2010;170:1648-1654.
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.32 October 10, 2016
Deprescribing simplified
1. Stop� Drugs that are unnecessary
� Duplicates
2. Shift� Safer for riskier
� Less costly alternative
� Non-drug treatment
3. Simplify� Dosing schedule
� Substitute one drug for two
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Simplified Geriatric Dosing
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
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From The New Yorker, November, 2015
34| © Kaiser Permanente 2010-2011. All Rights Reserved.
October 10, 2016
Med Reconciliation and Polypharmacy
MedRec
Adherence
CorrectDirections
Correct Dose
CostEffective
Omissions
Renal DoseAdjustments
UnclearOrders
Drug-Disease Interactions
Drug-Drug Interactions
Duplication
Drugs to Avoid in the Elderly
Side EffectsOTCs/Herbals
Is drug still
appropriate?
Indication
Hajjar ER, Calfiero AC, Hanlon JT. Polypharmacy in Elderly Patients. Am J of Geriatric Pharmacother 2007; 5(4); 345-51
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.35 October 10, 2016
Inside KP
Inside KP
� KPCO publishes polypharmacy intranet page
� KPGA addresses too-low HGBA1C and non-benzosedatives
� KPNW’s med rec aims to reduce polypharmacy
� DUM (Drug Utilization Management) program reverses trend in opioid prescribing
� MTM (Medication Therapy Management) stops unnecessary meds
Rita L. Hui, PharmD, MS; Brian D. Yamada, PharmD; Michele M. Spence, PhD;
Erwin W. Jeong, PharmD; and James Chan, PharmD, PhD. Impact of a Medicare MTM Program:
Evaluating Clinical and Economic Outcomes. Am J Manag Care. 2014;20(2):e43-e51
MTM
and
Comprehensive
Medication
Review
at KPAssociated with
- Lowered mortality
- Less hospitalization
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.37 October 10, 2016
4. Signs of the deprescribing era
� Beers list, Choosing Wisely, Direct-to-consumer media efforts
� More published medical literature,
algorithms
� CMMS incentives
� A cultural shift
O’Mahony D, et al. STOPP/START criteria for potentially inappropriate
prescribing in older people: version 2. Age Ageing. 2015;44:213-218.
Jetha S. Polypharmacy, the Elderly, and Deprescribing. The Consultant
Pharmacist. September, 2015;30(9):527-32.
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.38 October 10, 2016
2015 Beers List Criteria Update
� 1991 Criteria originated by Mark Beers
� 2011 AGS (Am Geriatrics Society) charged with review and updates
� 2015 Revision1
– Alternatives proposed2
– Serious Drug-Drug interactions itemized
– Drugs requiring renal failure dosing are listed
– Shifts in emphasis result from literature review
1 DOI: 10.1111/jgs.13702 JAGS, October 20152 DOI: 10.1111/jgs.13807
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.39 October 10, 2016
.
Polypharmacy in preventive cardiology1
Problem: Millions on CVD drugs* though proof of benefit lacking.� Short-term study results are extrapolated over decades.
� Results from young-old subjects are extrapolated to old-old.
� We have scant evidence on outcomes of drug withdrawals.
� Modern clinical practice differs from that when trials were conducted.
� Projections of benefits assume hazards are constant over time.
� Old-old adults may prefer different outcomes.
* Aspirin, beta-blockers, statins, ACE inhibitors
� How long should these drugs be continued?
1 J Am Coll Cardiol 2015;66:1273–85.
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.40 October 10, 2016
5. Benefits of Deprescribing
� Simplify care
� Reduce ADEs
� Reduce hospitalization
� Improve adherence
� Reduce costs
� Save lives
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Declining opioid use in KP 12/13 to 6/15
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.42 October 10, 2016
Case History Discussion
1. 45 yo on opioids for chronic pancreatitis reports unexpected death of his spouse.
2. 80 yo retired math teacher with dementia becomes a “zombie” after entering a NH.
3. 74 yo female diabetic in ED for falls has HGBA1C of 6%.
4. Wife says her 79 yo won’t take all his medicines.
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Bibliography
• InsidePatientCare.com Empowering Community Pharmacists as Health Consultants: Polypharmacy by Rebecca J. Mahan, PHARMD, CGP
• Brisbane, et al. Reducing Inappropriate Polypharmacy. JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324
• Tjia, et al. Use of Medications of Questionable Benefit…JAMA Intern Med. 2014;174(11):1763-1771. doi:10.1001/ jamainternmed.2014.4103
• Garfinkle D, Mangin D. Feasibility of a systemic approach… Arch Intern Med. 2010;170(18):1648-1654
• BMJ 2012:345:e6617 – Overtreatment – Is the USA’s problem ours too?
• BMJ 2012;345:e668 – Overtreament over here.
• Lam MP1, Cheung BM. The use of STOPP/START criteria as a screening tool for assessing the appropriateness of medications in the elderly
population. Expert Rev Clin Pharmacol 2012;5:187–197. (STOPP/START criteria)
• PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011. (STOPP/START
criteria)
• Frankenthal, et al. Intervention with the Screening Tool of Older Persons Potentially Inappropriate Prescriptions/Screening Tool to Alert Doctors to
Right Treatment Criteria in Elderly Residents of a Chronic Geriatric Facility: A Randomized Clinical Trial. J Am Geriatr Soc 62:1658–1665, 2014.
• Grounder, Celiine. “Who is responsible for the pain-pill epidemic?” The New Yorker, November 8, 2013.
• Moonen J et al. Effect of Discontinuing…JAMA Intern Med. doi:10.1001/jamainternmed.2015.4103 Published online August 24, 2015.
• Odden MC. (Editorial) JAMA Intern Med. Published online August 24, 2015. doi:10.1001/jamainternmed.2015.4309
• 2015 Beers Criteria Update: DOI: 10.1111/jgs.13702 and alternatives: DOI: 10.1111/jgs.13807
• Jetha S. Polypharmacy, the Elderly, and Deprescribing. The Consultant Pharmacist. September, 2015;30(9):527-32.
• Rochon P, Gurwitz J. Optimising drug treatment for elderly people: the prescribing cascade. BMJ, 1997; 315:1096-9
• Qato DM, et al. Changes in Prescription and Over-the-Counter Medication…2005 – 2011. JAMA Intern Med. Published online March 21, 2016.
doi:10.1001/jamainternmed.2015.8581
• Bemden MN.Deprescribing: An Application to Medication Management in Older Adults. Pharmacotherapy 2016;36(7):774–780) doi:
10.1002/phar.1776
Tools and collaborators
• http://www.medstopper.com
• http://www.open-pharmacy-research.ca/research-projects/emerging-services/deprescribing-guidelines
• https://clm.kp.org/wps/portal/cl/CO/result?url=/pkc/co/cpg/cpg/polypharmacy.html&category=Geriatrics&doctype=Guideli
nes&sdtype=Clinical&location=AdultCare&memberage=Adult%20Care&cntName=Polypharmacy%20in%20the%20Elderly
How to deprescribe
• (1) ascertain all drugs the patient is currently taking and the reasons for each one
• (2) consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention
• (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential
• (4) prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes
• (5) implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects.
JAMA Intern Med. doi:10.1001/jamainternmed.2015.0324
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