managing polypharmacy: thinking outside the [dosette] box
TRANSCRIPT
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Managing Polypharmacy:Thinking outside the [dosette] box
Martin Wilson
Consultant Physician
Care of the Elderly
NHS Highland
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What are we going to do?
• A quick run through core principles and challenges in Polypharmacy Management
• Example from the receiving unit
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Disclaimers
• Stopping drugs is not the primary goal
• Thinking openly and carefully is the goal
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Three overlapping areas
Multimorbidity Frailty
Polypharmacy
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Multimorbidity
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Barnett K, Mercer SW, Norbury M et al. Epidemiology of multi-morbidity and implications for healthcare, research, and medical education: a cross sectional study. The Lancet
2012:380:37-43
Multimorbidity is common
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Multimorbidity
Polypharmacy
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ISD
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Source ISD
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Multimorbidity Frailty
Polypharmacy
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Functional history as important as Past Medical History
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Steady Dwindiling
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Clegg et al. Frailty in elderly people. The Lancet, Vol 361, Issue 9868, 2013,752-762
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So how old is your patient?
• Lots of old folk who are physiologically younger than years
– Most of whom will be rich
• Lots of younger folk who are physiologically older than years
– Many of whom be deprived
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What category is your patient in?
Multimorbidity
Frail
Polypharmacy
FrailPolypharmacy
Multimorbidity PolypharmacyFrail
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What category is your patient in?
Multimorbidity
Frail
Polypharmacy
Frail Polypharmacy
Multimorbidity Polypharmacy Frail
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Stroke
Diagnosed
Diabetes Vascular
Dementia
COPD
Fall and
Lumbar
vertebral
fracture
Hospital
Admission
Recurrent
UTIs
MI
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Medication
• Metformin 1 g TDS
• Gliclazide 160mg bd
• Calcichew D3 forte 1 tab twice a day
• Alendronate 70mg once a week
• Perindopril 4mg once a day
• Indapamide 2.5mg once a day
• Seretide 250 1 puff twice a day
• Apixiban 5 mg twice a day
• Salbutamol as required
• Ipratropium Inhaler 4 times a day
• Clopidogrel 75mg once a day
• Atorvastatin 80mg once a day
• Mirtazapine 30mg nocte
• Zopicolone 7.5 mg at night
• Oxybutinin 5mg bd
• Thyroxine 150mcg once a day
• Ipratropium inhaler 4 times a day.
• Paracetamol 1g QDS
• Omeprazole 20mg once a day
• Trimethoprim 200mg once a day prophylaxis
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Medication
• DIABETES– Metformin 1 g TDS– Gliclazide 160mg bd
• OSTEOPOROSIS– Calcichew D3 forte 1 tab twice a
day– Alendronate 70mg once a week
• POST CVA– Perindopril 4mg once a day– Indapamide 2.5mg once a day– Apixiban 5 mg twice a day
• COPD– Seretide 250 1 puff twice a day– Salbutamol as required – Atrovent inhaler 4 times a day
• POST MI– Clopidogrel 75mg once a day– Atorvastatin 80mg once a day
• MOOD /BEHAVIOUR– Mirtazapine 30mg nocte– Zopicolone 7.5 mg at night
• BLADDER– Oxybutinin 5mg bd
• ENDOCRINE– Thyroxine 150mcg once a day
• OTHER– Paracetamol 1g QDS– Omeprazole 20mg once a day– Trimethoprim 200mg once a day
prophylaxis
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Emergency admission
• Crushing central chest pain at home
• Sweaty and clammy
• Resolved after morphine
• Now up and about on the ward. Confused looking for husband
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Tests
• Troponin >> lots
• ECG > Deep inverted anterior T waves/ AF (old)
• Chest X ray > mild congestion (but poor film)
• BP 98/40
• Urea 10 Creat 132
– Baseline Urea 8 / Creat 124
• WBC 8.6 Hb 98 MCV 92 Plat 140
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Diagnosis
• Acute Coronary Syndrome
• Delirium
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Management
• Cardiology
– Medical Management would not angio
– ECHO if tolerated
• Nursing
– Up and about a lot increasingly distressed
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So what is ‘medical management’ here ?
• Fondaparinux /Clopidogrel /Aspirin /Apixiban
– NO!
• Aspirin and Clopidogrel and Fondaparinux
• Clopidogrel and Apixiban
• Aspirin and Apixiban
• Aspirin and Clopidogrel
• Clopidogrel
• Aspirin
• ????
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How do guidelines help us manage these groups?
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Honesty about Guidelines
• Done with a SINGLE disease in mind
• Based on studies in non- frail
• Are not made with the frail or multimorbid in mind
• They are GUIDElines but– Can be VERY hard to ‘defy’ them
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• Almost no trial evidence in frail adults
– Different pharmacology
– Huge comorbidity
• Use the best we have ie younger adults
– Different Absolute Risk
– Different Harm rates.
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• Almost no trial evidence in frail adults
– Different pharmacology
– Huge comorbidity
• Use the best we have ie younger adults
– Different Absolute Risk
– Different Harm rates.
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Why did you jump off a cliff?
Because the Guideline told me to.
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Game changing concepts
If guideline says Prescribe X drug it is GUIDANCE not INSTRUCTION and not prescribing may well be acceptable (and often desirable) in a range of situations
One size does not fit all.....
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Beware Extrapolation
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Rivaroxaban with or without Aspiring in Stable Cardiovascular Disease Eikelboom et al NEJM
2017; 377 (14) 1319 - 1330
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Comparative effectiveness of high-dose versus standard-dose influenza vaccination on
numbers of US nursing home residents admitted to hospital: a cluster-randomised trial
Gravenstein S et al., Lancet Respir Med. 2017;5(9):738-46).
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– What are the patients priorities likely to be?
– What are there carers priorities likely to be?
– What are the Health Service Priorities likely to be?
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Medication
• Metformin 1 g TDS
• Gliclazide 160mg bd
• Calcichew D3 forte 1 tab twice a day
• Alendronate 70mg once a week
• Perindopril 4mg once a day
• Indapamide 2.5mg once a day
• Seretide 250 1 puff twice a day
• Salbutamol as required
• Ipratropium Inhaler 4 times a day
• Clopidogrel 75mg once a day
• Atorvastatin 80mg once a day
• Mirtazapine 30mg nocte
• Zopicolone 7.5 mg at night
• Oxybutinin 5mg bd
• Thyroxine 150mcg once a day
• Ipratropium inhaler 4 times a day.
• Paracetamol 1g QDS
• Omeprazole 20mg once a day
• Trimethoprim 200mg once a day prophylaxis
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Medication in the Frailest Adults
• Blood pressure - avoid blood pressure < 130 systolic and or < 65 diastolic [except in LVSD]
• Blood sugar control - avoid lowering HbA1c < 65
• Treatments to maintain renal function and avoid progression of proteinuria - avoid treating unless considered to have sufficient life expectancy to see benefit
• Use of blood thinners - avoid the use of combination blood thinners
• Heart rate control - reduce or stop heart rate limiting medication if pulse < 60
Polypharmacy Guidance, Realistic Prescribing 3rd Edition, 2018. Scottish
Government Polypharmacy Model of Care Group.
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This lady
• Aspirin or Clopidogrel alone
• A lot less of her other medication….
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Facts and figures• BP 106/56
• HbA1c 40 mmmol/mol 5.8%
• Urine Albumin/Creat ratio – trace microalbuminuria
• Creatinine 124 eGFR 45
• ECG Atrial Fibrillation 62 bpm
• Weight 43kg
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?
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?
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?
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?
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?
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?
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?
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• [Postural] Blood Pressure too low ?
• Blood Sugar too low?
• Blood too thin [ed]?
• Kidneys too vulnerable?
• Any Messy drugs ?
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Three Take Home Messages
• Addressing Polypharmacy begins and ends with individualised patient defined goals
• Frailty is a more useful concept than chronological age
• Better knowledge of efficacy and risk can aid decision making