de-prescribing medications in pace: case-based …...npa annual conference 2016 kevin t. bain,...

NPA Annual Conference 2016

Kevin T. Bain, PharmD, MPH

Rachel Broudy, MD

De-Prescribing Medications in PACE:

Case-Based Approaches

NPA Annual Conference 2017

Disclosures

• Kevin Bain: None to Report

• Rachel Broudy: None to Report

Objectives

(1) Describe a theoretical framework for reducing polypharmacy in the

elderly

(2) Articulate a systematic approach for de-prescribing in PACE,

addressing polypharmacy

(3) Apply the principles and systematic approach to PACE participant case

scenarios

Theoretical Framework and Systematic

De-Prescribing Approach in PACE

Kevin T. Bain, PharmD, MPH

[email protected]

mailto:[email protected]

Definition of De-Prescribing

• The systematic process of identifying and discontinuing drugs in which existing

or potential harms/risks outweigh existing or potential benefits within the

context of an individual patient’s care goals, current level of functioning, life

expectancy, values, and preferences

• De-prescribing is not about denying effective treatment

It is a positive, patient-centered intervention…and requires the same good prescribing

principles that apply when drug therapy is started

Scott IA, et al. JAMA Intern Med. 2015;175(5):827-34.

Reasons

WHEN TO CONSIDER DE-PRESCRIBING

Pop Quiz!!!

• The most common reason for de-prescribing is actual increased risk

A. True

B. False

Reasons to Consider De-prescribing

• Increased risk (actual) Patient is experiencing or has experienced a problem (e.g., side effect)

For example, new presentation of symptom, possibly representing an ADE

• Increased risk (potential) Patient is likely to experience a problem (e.g., adverse drug event)

For example, high risk medication (HRM) use in the elderly (e.g., fall)

• Lack of indication No clear, documented & current indication for medication use

For example, continued / long-term PPI use following initiation in the hospital

• Preventative benefit retained after stopping medication For example, continued osteoporosis prevention with bisphosphonate



• No or limited benefit Medication was never or only slightly effective in the first place, or

Time needed for medication benefit is shorter than patient life expectancy

For example, advanced disease / terminal illness

• Diminished benefit Medication is not as effective as it was initially, or

Medication treatment target no longer meets goal of care for patient

For example, anti-dementia medication >5-10 years of use / in progressive dementia

• Poor medication adherence Intended benefit not realized or potential harm


Reasons to Consider De-prescribingPolypharmacy

Atkin PA, et al. Drugs Aging. 1999;14(2):141-52.

http://health.gov/hai/ade.asp.

Doan J, et al. Ann Pharmacother. 2013;47(3):324-32.

The risk of an adverse drug event (ADE)

is 81% with ten or more medications.

OBVIOUS

82% of patients taking >8 drugs use at least one potentially

inappropriate medication (PIM).

The probability of >1 clinically-relevant DDI is 50% in geriatric

patients taking 5-9 medications, 81% with 10-14 medications, 92%

with 15-19 medications, and 100% with >20 medications.


OBVIOUS

Medication storage


OBVIOUS

Start U-500?


• What do we do when it is not so obvious?

• How do we determine when & which medications to de-prescribe?

The concept of Medication Utility

The term “medication utility” refers to whether a medication is useful in an individual clinical situation based on both the attributes of the

medication and those of its recipient

Let’s take a close look at some theoretical frameworks

Theoretical Frameworks

HOW TO DETERMINE DE-PRESCRIBING

Take a Deep Breath

Medication Utility in GeriatricsWhy Should We Evaluate?

• Inappropriate medication use is prevalent

• Polypharmacy – use of multiple medications concomitantly

More medications added towards the end of life!

Risk of drug interactions & adverse drug events!

• Fragile health

• Short(er) life expectancy

• Goals of care – symptom management & QoL

Framework 1

Homes HM, et al. Arch Intern Med. 2006;166(6):605-9.

less time palliative

curativemore time

Medication Utility in GeriatricsHow Should We Evaluate?

Benefit-Risk Ratio

Population

Individualized Patient

Assessment

Benefit-Risk Ratio

Individual

Medication Utility in GeriatricsBenefit-Risk Ratio – Population

• Benefits

Efficacy at population level

Number Needed to Treat (NNT)

• Risks

Safety data from trials & post-marketing surveillance

Number Needed to Harm (NNH)

Medication Utility in GeriatricsIndividual Patient Assessment

• Will the patient benefit from the medication?

Does the patient’s remaining life expectancy exceed the medication’s

time until benefit being achieved?

• Is the medication a logical part of the patient’s treatment plan?

Compare the patient’s goals of care to the medication’s treatment target



Remaining Life Expectancy

Holmes HM, et al. Arch Int Med. 2006;166(6):605-9..

Walter LC, et al. JAMA. 2001;285(21):2750-6.

Walter LC, et al. JAMA. 2001;285(23):2987-94.


Time Until Benefit

• Minutes/HoursAnalgesics

• MonthsBisphosphonates in osteoporosis

• YearsTight glycemic control in diabetes mellitus

• More difficult for othersStatins?

Holmes HM, et al. Arch Int Med. 2006;166(6):605-9.

Holmes HM, et al. Drugs Aging. 2013;30(9):655-66.


Goals of Care

• Prolong life

• Prevent morbidity

• Slow disease progression

• Prevent decline

• Comfort

Treatment Targets

• Primary prevention

• Secondary prevention

• Control chronic diseases

• Treat acute disease

• Medications for symptoms

Holmes HM, et al. Arch Int Med. 2006;166(6):605-9..

Sachs GA. J Amer Geriatr Soc. 1998;46(6):782-3.


more time


curative

Putting it all together


Medication Utility in GeriatricsBenefit-Risk Ratio – Individual

• Benefits Effectiveness in an individual patient

Cost

• Risks Adverse drug reactions (ADRs)

Adverse drug events (ADEs)

Drug interactions (drug-drug, drug-gene)

Comorbidities

Changing physical and/or functional status

Hierarchy of Medication UtilityTheoretical Framework Applied to Hospice


more time curative

Low Utility

Questionable

Utility

High Utility


Nonessential Medications

of Palliative Care

Medications with Uncertain

Utility

Essential Medications of

Palliative Care

Amitriptyline

Bisacodyl

Dexamethasone

Gabapentin

Haloperidol

Senna

Dickerson D. Eur J Palliat Care. 1999;6(4):130-5.

De Lima L, et al. J Pain Palliat Care Pharmacother. 2007;21(3):29-36.


• FG is a 72-year-old man admitted to hospice for metastatic lung cancer

• Other past medical history Heart failure

Emphysema

Hypertension

Coronary artery disease

• Medications include the following: Furosemide

Lisinopril

Tiotropium

Simvastatin

Multivitamin

Case Scenario 1


Case Scenario 1

Essential

Uncertain

Nonessential

Benefit-Risk Ratio

Population


Assessment

Benefit-Risk Ratio

Individual


Case Scenario 1

furosemide

lisinopril

tiotropium

simvastatin

multivitamin

Benefit-Risk Ratio

Population


Assessment

Benefit-Risk Ratio

Individual


• BB is a 90-year-old male enrolled in hospice for end-stage Alzheimer’s disease (FAST 7-c)

• PMH includes chronic constipation, pressure ulcers and osteoarthritis

• BB is noted to be agitated and has lost 20 pounds over the past 3 months His caregiver (daughter) reports that he has experienced difficulty swallowing

and dry mouth over the same time period

Upon further inquiry, she indicates that her father started taking Tylenol® PM for sleep about 4 months ago after his wife passed away

• He ambulates with the assistance of a cane

Case Scenario 2


• His medications include the following:

Donepezil 10mg/day

Memantine 10mg/day

Celecoxib 200mg/day

Diphenhydramine-acetaminophen 25-500mg (Tylenol® PM) at bedtime

Folic acid 1mg/day

Vitamin C 500mg twice daily

Docusate 100mg twice daily

Case Scenario 2


• Which of B.B.’s medications should be considered for

discontinuation?

A. Folic acid

B. Vitamin C

C. Diphenhydramine-acetaminophen

D. All of the above

Case Scenario 2

Framework 2


Garfinkel D, et al. Isr Med Assoc J. 2007;9(6):430-4.

Framework 3

Framework 3Good Palliative-Geriatric Practice Algorithm

• Among 70 community-dwelling older adults enrolled:

Baseline mean of 7.7 medications

Followed for a mean of 19 months

• Results:

91% of subjects eligible for de-prescribing of at least 1 medication

58% of all medications were eligible for de-prescribing (n=311)

81% of drugs were de-presribed successfully

88% of subjects reported global improvement in health

Garfinkel D, et al. Isr Med Assoc J. 2007;9(6):430-4.

Bain KT, et al. J Am Geriatr Soc. 2008;56(10):1946-52.

Framework 4

Systematic Approach

HOW TO DE-PRESCRIBE

Beware

Systematic De-Prescribing Approach

1. Recognize a Reason

2. Identify & Prioritize

3. Plan, Communicate, & Coordinate

4. Monitor

Abrupt or

Gradual Discontinuation

ADWEs and/or Improvement

(e.g., ADR or ADE)

De-Prescribing Techniques

Gradual

Discontinuation

Abrupt

Discontinuation

Stop Slow as you Go Low !!

Adverse Drug Withdrawal Events (ADWEs)

• Defined as any noxious, unintended, and undesired effect of

discontinuing a medication

• Clinical manifestations of an ADWE:

Physiological withdrawal

Exacerbation of underlying condition

New set of symptoms

Bain KT, et al. J Am Geriatr Soc. 2008;56(10):1946-52.

Adverse Drug Withdrawal Events

• A study of 124 ambulatory elderly participants at the Durham VA

General Medicine Clinic who stopped taking medications

• ADWEs occurred in 30% of patients

88% exacerbation of underlying disease

Cardiovascular medications

CNS medications

1/3 resulted in urgent visit (e.g., urgent care, ED, hospitalization)

Median time to ADWE = 35 days

Range up to 4 months

No consistent deprescribing approach employed

Graves T, et al. Arch Intern Med. 1997;157(19):2205-10.

Application to Patient Case Scenario

PRACTICAL DE-PRESCRIBING

Systematic Approach ExampleHigh-Risk Medications (HRM)

1. Recognize anticholinergic burden

2. Avoid use or de-prescribe

3. Plan, Communicate, & Coordinate

4. Monitor

Abrupt or

Gradual Discontinuation

Cognitive function and/or ADWEs

Individual drug and cumulative

Highly Anticholinergic

Drugs

Change to alternative

or discontinue drug

Systematic Approach ExampleStep 1: Recognize

• Pharmacist identifies drug(s) with high anticholinergic burden

Aided by computerized decision support

High anticholinergic burden is associated with cognitive & physical

dysfunction

Score 1 Score 2 Score 3

Alprazolam Carbamazepine Amitriptyline

Bupropion Cyproheptadine Oxybutynin

Ranitidine Meperidine Olanzapine / Quetiapine

Risperidone Oxcarbazepine Tolterodine

Anticholinergic Cognitive Burden Scoring of Drugs

Systematic Approach ExampleStep 2: Prioritize

• Pharmacist makes recommendation to prescriber to change to

alternative drug or discontinue

What is the drug & indication?

Amitriptyline

– Depression: sertraline, citalopram, escitalopram, bupropion, duloxetine

– Neuropathic pain: duloxetine, gabapentin, pregabalin, capsaicin, lidocaine

– Insomnia: trazodone

Oxybutynin

– Incontinence: non-pharmacologic interventions (e.g., scheduled toileting)

Systematic Approach ExampleStep 3: Plan, Communicate & Coordinate

• Pharmacist provides recommendation for de-prescribing

technique(s)

Amitriptyline 50mg at bedtime for insomnia

Reduce dose by 10-25mg every 5-7 days

Monitor symptoms +/- need for alternative drug

Oxybutynin 10mg twice daily for incontinence

Start scheduled toileting and diary

Reduce dose by 50% & evaluate for 72 hours

Discontinue drug after 72 hours, if feasible

Monitor success of non-pharmacologic intervention

Systematic Approach Example Step 4: Monitor

• PACE physician discussed the negative anticholinergic effects of the drugs with

Mrs. Doe

• De-prescribing was initiated

• Follow-up visit 1 week later indicated successful management of UI & insomnia

Plan to complete discontinuation of oxybutynin & continue reduction of amitriptyline

• By 3 months later, Mrs. Doe’s MMSE score increased from 20 to 23

Her anticholinergic cognitive burden score was 2, which was a decrease from 8

Application of De-Prescribing

to Real World Cases

Rachel Broudy, MD

[email protected]

mailto:[email protected]

Disclosures

Why don’t we de-prescribe?

www.dreamstime.com

Why don’t we de-prescribe?

• Medical guidelines

• Not knowing why someone is on a medication or how long they have been on it

• Not wanting to change specialist recommendations

• Lack of clarity about life expectancy / goals of care

• Fears about withdrawal or recurrence of symptoms

• Time

• Participant preference

Our Case

• A 75 year old male with CHF, DM, COPD and CAD, lives in

assisted living and is functional, able to complete most of his ADLs

with minimal assistance from staff at ALF. But has some mild

dementia, needs help with medications and personal care.

Medical Guidelines

• DM

Metformin 500mg tid

• CAD

Simvastatin 80mg qhs

Aspirin 81mg qd

• COPD

Tiotropium 18mcg qd

Fluticasone propionate/

salmeterol 250/50 1 puff bid

• CHF

Furosemide 40mg bid

Spironolactone 25mg bid

Lisinopril 10mg qd

Metoprolol succinate 100mg qd

9 Medications (14 meds a day!)

before even moving on to

symptoms.

He also has insomnia, GERD and

osteoporosis.

Unknown History

• This same 75 year old male with CHF, DM, COPD and CAD also has on his

med list:

omeprazole 40mg qam

calcium and vitamin D, 600mg/200IU bid

alendronate 70mg qweek

clopidogrel 75mg qd

gabapentin 300mg qhs

trazodone 50mg qhs

• Now we are at 15 medications, all of which seem somewhat reasonable

individually.

15 Medications

Metformin 500mg tid

Simvastatin 80mg qhs

Aspirin 81mg qd

Tiotropium 18mcg qd

Fluticasone propionate/

salmeterol 250/50 1 puff bid

Furosemide 40mg bid

Spironolactone 25mg bid

Lisinopril 10mg qd

Metoprolol succinate100mg qd

Omeprazole 40mg qd

Ca/Vit D 600/200 bid

Alendronate70mg qwk

Clopidogrel 75mg qd

Gabapentin 300mg qhs

Trazodone 50mg qhs

Pharmacy Review

Polypharmacy

Specialist Recommendations

• My heart doctor put me on these medications and I’ve been fine

since then so I don’t want to go off them.

• They told me in the hospital I need these medications.

• My daughter says I should take a multivitamin every day

Goals of Care and Physician Fears

• If these medications are helping me, I’ll keep taking them. I’m not

ready to die yet.

• What if I stop the statin and he has an MI?

• What if I stop the Fosamax and he falls and has a hip fracture?

• What if I stop the PPI and he has a GI bleed?

• What if I stop the spironolactone and he goes into heart failure?

Time

• Every time he has a clinic visit, he has an acute issue, a cold,

insomnia, irritation with transportation, chest pain.

• There’s never time to do a complete medication review. Or a good

time to try down-titrating some of his chronic medications because

there’s always something acute and being a good geriatrician, you

don’t want to change too much at once.

Participant Preference

Is It Safe to De-prescribe?

• Garfinkel and Mangin published an article in the Archives of Internal Medicine

in 2010* and applied the Good Palliative-Geriatric Practice algorithm to 70

community dwelling older adults to recommend drug discontinuation.

• Mean age 82.8 years

• 61% had 3 or more comorbidities, 26% had 5 or more

• They recommended discontinuation of 58% of drugs (!), only 2% of which were

restarted

*Garfinkel D, Mangin D. Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older

Adults. Arch Intern Med. 2010;170(18):1648-1655.

Good Palliative-Geriatric Practice algorithm

(revised by Garfinkel)

What did the study show?

It works!

• “Discontinuation of a mean (range) 4.2 (1-11) different medications

in the cohort was safely achieved with no significant adverse events

or deaths related to discontinuation. Only 2% of drugs had to be

readministered; in 88% of elderly patients, application of the GP-GP

algorithm was associated with subjective clinical, functional, mood,

or cognitive improvement.”

So what do we do and how do we do it?

Theoretical Framework 2


Methods for Implementing De-prescribing

• Review need for medications in light of goals of care or when moving from one pathway to

another (longevity, functional, palliative)

• Use your pharmacist for participant medication reviews at transitions of care or in a more

targeted fashion

By medication (population-based, review all people on ppi’s)

By individuals (at transitions or other times)

Risk-based analysis (top 15% of patients with highest number of medications or highest

anticholinergic or sedative burden)

• Use your EHR

Goals in the care plan: reduce medications by 2 in next 6 months

Polypharmacy as a care plan problem (PCP, RN, ICHA)

New admission to Mercy LIFE

• 84 year old female, living at home with stressed out family caregivers

• Diagnoses on admission:

dementia

hypertension

osteoporosis

chronic kidney disease

anemia

urinary incontinence

hyperlipidemia

New Admission to Mercy LIFE

• On admission, medications are as follows: Donepezil 10mg qd

Lovastatin 40mg qhs

Magnesium oxide 400mg qd

Metoprolol tartrate 50mg bid

Quetiapine 25mg qam

Sertraline 12.5mg qam

Hydrochlorothiazide 12.5mg qd

Levetiracetam 500mg bid

Losartan 100mg qd

Omeprazole 20mg qd

New Admission – Exam

• She is completely agitated, leaves the room swearing and shaking

her fist. Sentences complete, not disorganized, but not related to

current place, people, events

• Frail, cachectic

• 88 lbs (BMI 16.8)

• 97% RA, 96/60, 60, Afeb

• Exam deferred

Method for De-prescribing: Goals of care

• It is clear that though she is new to the program, the goals around

her care should be more palliative in nature.

• She has end-stage dementia with behaviors threatening her safety

and safety of those around her.

• She has trouble swallowing pills and is cachetic.

• What can we get rid of? And in what order?

Framework for De-prescribing

• No benefit

• Harm greater than benefit

• Treatment of non-existent (past, resolved, erroneous) symptoms or

diseases

• Preventive medications that won’t be beneficial over limited life

expectancy

New Admission to Mercy LIFE

• On admission, medications are as follows: Donepezil 10mg qd

Lovastatin 40mg qhs

Magnesium oxide 400mg qd

Metoprolol tartrate 50mg bid

Quetiapine 25mg qam

Sertraline 12.5mg qam

Hydrochlorothiazide 12.5mg qd

Levetiracetam 500mg bid

Losartan 100mg qd

Omeprazole 20mg qd

Review of her individual risk profile

• High anticholinergic burden: quetiapine

• High sedative burden: quetiapine, sertraline, levetiracetam

• Long QT syndrome: donepezil, quetiapine, hctz and sertraline

• Competing medications: lovastatin is high affinity for same receptor as

donepezil, weak affinity (CYP3A4) so higher levels of donepezil in blood

currently. Same for donepezil and metoprolol, high affinity for CYP2D6. So

even higher levels of donepezil on board.

Also, anticholinergic effects of quetiapine counteract cholinergic effects of

donepezil, which makes donepezil LESS effective

Sertraline levels increased by simultaneous use with quetiapine and ppi

(again, enzymes CYP3A4 and CYP2C19)

Plan

• Increase Seroquel over the weekend to two tabs bid or two bid with

one prn dose to see if that is effective for symptoms. If not, d/c that

and try something else.

• Stop: statin, magnesium, HCTZ and sertraline

Plan Part 2

• Get medical history for seizures and clarify need for levetiracetam

• Trial off omeprazole when other issues stabilized

• Clarify if quetiapine works and if not, d/c

• Depending on goals of care and treatment of symptoms of agitation,

could try down-titration of donepezil as well

• That’s all her medications!

Follow up

64 year old female on 28 meds!

• 64 year old F with major recurrent depression and trauma history,

CAD, COPD (still smoking), DM, obesity, HTN and chronic pain.

• Her med list includes 28 meds!

• PRNs: albuterol nebs, Colace, icy hot patches so only 25

• (I don’t feel any better)

64 year old female on 28 meds!

Why 25 medications?

• DM with neuropathy: metformin, lantus, SSI, gabapentin

• CAD/HTN: clopidogrel (ASA intolerant), atenolol, isosorbide mononitrate,

lisinopril (off statin due to s/e currently)

• COPD: fluticasone/salmeterol, tiotropium, prn nebs and prn albuterol inhaler

• IBS: fiber, PPI, senna

• Chronic pain: oxycodone, tylenol

• UI: oxybutynin

• Major depression with trauma: fluoxetine, ziprasidone, clonazepam, trazodone

• Other: B12 IM qmonth, levothyroxine, flonase, vit D

Methods for De-prescribing

• Targeted pharmacy review

• But again, can also ask for pharmacy reviews in a more

standardized way that is built into a QAPI plan such as:

Decrease the number of patients with dementia on anti-psychotics over the

next year

Decrease our use of PPI’s over the next year by 10%

Review top 10% of patient at high risk for medication adverse effects over

the next year (top 10% sedated, # of meds, anticholinergic burden, etc)

Pharmacy Risk Profile

Strong anticholinergics

Oxybutynin

Strong sedatives

Clonazepam

Fluoxetine

Oxycodone

Gabapentin

Trazodone

Ziprasidone

Polypharmacy

Fairly obvious: 25 medications!

Long QT Syndrome drugs

Fluoxetine

Pantoprazole

Trazodone

Ziprasidone

Example of a pharmacy review

High risk meds – what can we d/c?

• Gabapentin – she refuses to d/c

• Atenolol – I think she needs BB due to her CAD and high cardiac risk

• Isosorbide mononitrate – it’s been the only thing that has worked for her HTN

• Lisinopril 40mg – I think she needs it for BP control and renal protection with DM

• Pantoprazole – she refuses to d/c, insists ranitidine doesn’t work

• Oxycodone – this is as good as it’s going to get

• Oxybutynin – she wants to continue this for QOL

• Fluoxetine – has been on it 20y, refuses trial off

• Ziprasidone – only medicine that has helped her since I’ve known her

• Trazodone – she still insists she sleeps poorly and wants more

• Clonazepam – not touchable at this point

Now what?

• Motivational interviewing!

• Very gradual changes as we build trust and clinical improvement.

• Where should we focus?

High risk meds – what can we change?

• Gabapentin – she refuses to d/c

• Atenolol – I think she needs BB due to her CAD and high cardiac risk

• Isosorbide mononitrate – I think she needs it for anginal sx

• Lisinopril 40mg – I think she needs it for BP control and renal protection

• Pantoprazole – she refuses to d/c, insists ranitidine doesn’t work

• Oxycodone – this is as good as it’s going to get

• Oxybutynin – she wants to continue this for QOL

• Fluoxetine – has been on it 20y, refuses trial off

• Ziprasidone – only medicine that has helped her since I’ve known her

• Trazodone – she still insists she sleeps poorly and wants more

• Clonazepam – not touchable at this point

Motivational Interviewing

• Engage participants in a conversation in order to motivate change

• Address the area(s) where change is desired

• Elicit from the participant their own motivation for making the change

• Elicit a plan from the participant to make this change

• Based on autonomy, collaboration, evocation and exploration (v. authority,

confrontation, education and explanation)*

*Freedman, J; Combs, G. (1996). "Narrative Therapy: The Social Construction of Preferred Realities". New York: Norton.

Motivational Interviewing

• You are on 4 medications for your mental health. Do you think you need all these

medications? Which ones do you think helped you? Which ones cause you side

effects?

• Clonazepam can cause or exacerbate depression. What if we just tried decreasing the

dose from 1mg tid to 0.5mg qam and continue the 2mg bid as before?

• Or, you have been on fluoxetine for a long time. Do you think it is helping you? It can

increase fatigue and the risk of cardiac arrhythmias. Maybe a decrease in dose would

make you feel better.

• Or, I know you have said you hate being on all of these medicines. Let’s review them

all and you chose one that you would like to decrease or stop and we can try that and

see how you feel. We can always re-start it if you don’t like how you feel off it.

MI – patient focused decision making

• You are worried about your heart and having a heart attack. The

Clopidogrel is not working now with some of your other

medications. Are you willing to try going off the pantoprazole and

see how you feel?

• I know the oxybutynin helped your urinary symptoms at night. What

if we could get you that help with fewer side effects, like dry mouth

and light-headedness?

Barriers?

• Time! She always has an acute issue. Is seen in clinic every week,

sometimes more.

• Solutions?

• Using the medical record to help trigger these reviews.

Use of EHR to help with polypharmacy

• Add the problem to the reason for visit

Use of EHR to help with polypharmacy

• Make polypharmacy it’s own medical problem

Adding Polypharmacy to the Problem List

Change in Condition or Transitions of Care

• 77 year old man joined program with dementia with behavior issues

and/or personality issues, DM, BPH, tremor, major depression with

anxiety.

• He is on a long list of medications and neither him or his son know

who started several of them and why he is on them.

Initial Medication List

• B12 1000mcg qhs

• vit D3 2000 IU daily

• omeprazole 20mg qd

• colace 100mg bid

• senna 1 tab qhs

• miralax daily

• memantine10mg qd

• finasteride 5mg

• tamsulosin 0.4mg qhs

• oxybutynin ER 5mg daily

• pravastatin 20mg

• glipizide 2.5mg bid

• paroxetine 40mg

• lamotrigine 200mg daily at

• primidone 150mg qam and 100mg

qpm

• mestinon 60mg tid

• trazodone 25mg bid prn

• buproprion XL 300mg daily am

Change in Condition

• Soon after enrollment he develops new onset ascites and

pulmonary edema due to undiagnosed cirrhosis. He is admitted to

the hospital for treatment. He is diuresed and medications are

added for his ascites.

• So PCP asks pharmacy for a review of medications in light of his

liver disease.

Harm or benefit?

Medication Review

• Memantine – taper off, not at full dose, not clear there is benefit

• Mestinon – for tremors, harm>benefit, taper off

• Tamsulosin with many s/e and drug interactions but urinary frequency is his

biggest complaint so kept it for QOL

• Buproprion decreased to 75mg qd due to hepatic dosing

• Tapered down paroxetine and lamotrigine

• Trazodone was a prn, stopped this

Implementation of De-prescribing

• Entry of polypharmacy into LIFEplan with plan noted there with

pharmacist recommendations

• Repeating monthly clinic visit x 6 for polypharmacy

• Family meeting to review prognosis, goals of care

Family Meeting

• Reviewing goals of care and

life expectancy with participant

and family, we elicited goals for

function, quality of life, and not

too many meds, and made

adjustments based on that.

Theoretical Framework 2


Using QAPI to help with polypharmacy

• Ask your pharmacists for a list of everyone on a medication or

medication class that you would like to review for appropriateness.

PPIs

Anti-psychotics

Statins

Or all those on 10 or more medications

• Arrange monthly medication review for those participants in clinic to

follow up on the indications for these medications

Last Minute Tips

• Medications to think about:

PPIs – risks for adverse reactions and events (e.g., C. diff diarrhea, falls)

Anticholinergic & sedative burden – risks for cognitive & physical

dysfunction

Polypharmacy – risks for falls and poor outcomes

Beers Criteria drugs – risks for poor outcomes

Bisphosphonates – use only 5y, benefit begins after 1.5y of tx, risk of

atypical fx increases after 2-5y of therapy

Last Minute Tips 2

• Conditions to think about:

Statins for primary prevention – LE should be at least 2y to gain benefit

(length of studies)

DM – 10 years to develop proteinuria. Do you need the ACEI?

Aspirin – needed 5 years to decrease risk of MI in pts with DM

So what do we do and how do we do it?

• Safety: drug interactions, high risk medications

• Goals of care and participant preference

• Life expectancy and review of preventive medications

• Transitions of care

• QAPI

Audience Discussion

• Your experiences?

• Challenges?

• Successes?

• Standardized care plan interventions?

• Tools or strategies to increase participant buy-in?

de-prescribing medications in pace: case-based …...npa annual conference 2016 kevin t. bain,...

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