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Optimizing Drug Prescribing in the Elderly

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Mihaela Nicula

on 8 November 2013

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Transcript of Optimizing Drug Prescribing in the Elderly

Successful Pharmacotherapy
More Diseases
Physiologic Changes
due to Normal Aging
Adherence
Socio-economic factors

Pharmacokinetics
Absorption
Distribution
Metabolism
Elimination
Pharmacodynamics
Drug-Drug Interactions
Drug-Disease Interaction
OPTIMIZING DRUG PRESCRIBING
IN THE ELDERLY

Identify the physiologic changes associated with normal aging in relation to drug absorption, distribution, metabolism and secretion
Identify the risk factors for Adverse Drug Events in older adults
Recognize potentially harmful medications for older adults
Utilize strategies to enhance the safety, effectiveness and adherence of prescribed medications
Mihaela Nicula, MD,FRCPC
Geriatric Medicine

Learning Objectives
Correct indication
Correct formulation
Correct dosage
Evaluate short-term and
long-term outcomes
Respect for patient's values
No clinically significant decline with normal aging
Rate of absorption can be slowed
- peak serum concentration decreases
- t delayed
Normal aging
Conditions affecting absorption
Drugs
malabsorbtion
gastric/small bowel surgeries
gastric acid suppresants - absorption nifetipine, amoxicilline
- absorption vit B 12, ampicillin, imidazole anti-fungals
metformin - vit B 12
drugs affecting G-I motility (laxatives, domperidone, metoclopramide)
Enteral feeding
absorption of some drugs (phenitoin, levothyroxin)
Monitor clinical response
Monitor drug levels
Consider alternative formulations
Normal aging
Decresed body water
Decreased lean body mass
Disease states
Decreased plasma albumin
Decreased binding of some drugs, free drug
warfarin
ceftriaxone
lorazepam
valproic acid
phenitoin
Increased toxicity
ABSORPTION
DISTRIBUTION
METABOLISM
ELIMINATION
Normal aging
Average
decline in GFR
after mid-30s
6-12 mL/min/1.73 m
per decade
Normal aging
2
Medical conditions affecting elimination
HTN nephrosclerosis
DM nephropathy
Obstructive uropathy
Acute renal injury due to hypoperfusion
FDA-labeled dosing based on
Cockroft-Gault equation estimated CrCl
eGFR may result in suboptimal dosing especially
in Stage 2 CKD
Competition for protein binding
Drugs affecting elimination
Diuretics
Nephrotoxic drugs
decreased hepatic blood flow
decreased Phase I liver metabolism (cytochrome P-450 system)
eg., clopidrogel less effective
Phase II liver metabolism (glucuronidation, conjugation/acetylation) not much changed
Diseases
hepatic congestion due to CHF
cirrhosis
Drugs affecting cytochrome P-450 system
Phase I
Phase II
diazepam
phenitoin
carbamazepine
desipramne
glyburide
clopidogrel
lorazepam
oxazepam
temazepam
NSAIDs
phenitoin
valproic acid
warfarin
sulfa
sulfonylureas
Normal aging

Elderly more sensitive to benzodiazepines, narcotics, anticholinergic drugs
Disease related changes
Dementia - increased sensitivity to anti-cholinergics
Parkinson disease - increased sensitivity to neuroleptics
Drug-drug interaction
Synergy (benzodiazepines and antidepressants)
Receptor antagonism
Pharmacotherapy in the Elderly
Polypharmacy
Herbal and dietary supplements
Complex medications regimes
Cognitive impairment
Functional impairment
Diet
Fluid intake
ABSORPTION
max
Hydrophilic drugs
Vd, peak serum concentration
ethanol
lorazepam
digoxin
aminoglycosides
acetaminophen
Lipophilic drugs
Vd, half-life
diazepam
sotalol
antipsychotics
amiodarone
fluoxetine
DISTRIBUTION
Drugs
Follow-up CrCl
Dose adjustment
Serum drug concentrations
Monitor for clinical signs of toxicity
Validated screening tool of PIM (potentially inappropriate medications)
in elderly patients
65 PIMs listed by physiological systems (CV, CNS, GI, etc)
STOPP also screens for:
Drug–drug interactions (e.g. anticholinergic medications and
cholinesterase inhibitors such as Aricept)
Drug–disease interactions (e.g. NSAIDs with heart failure)
Drugs which increase risk of falls in the elderly
Therapeutic duplication (e.g. 2 ACEI, 2 SSRIs, etc.)
Can be used by all disciplines involved in the care of older patients (primary care, specialists, pharmacists) to assess appropriateness of drug treatment, minimise the risk of ADRs and related morbidity.
Screening Tool of Older People's Potentially Inappropriate Prescriptions (STOPP)
START - an evidence-based screening tool to detect prescribing omissions in the elderly patients
Screening Tool to Alert Doctors to the Right Treatment (START)
Hospital-Wide Grand Rounds
Tuesday, February 19, 2013

hello
Decline in renal function
blood flow
number of functioning nephrons
tubular secretion

Are the commonest > 3/4 of all ADRs
Quantitative and predictable
Caution when combining drugs with additive effects
Adverse Drug Events (ADEs)
Adverse Drug Reactions (ADRs)
Premarketing trials often exclude geriatric patients and approved doses may not be appropriate for older adult

Guidelines not helpful in managing patients with multiple conditions
Cho S. et al, Arch Intern Med 2011
Review explicit recommendations for caring for the elderly, patients with
co-morbid conditions, advice for providing patient-centered care in
5 NICE guidelines (DM2 , post-MI care, OA, COPD, depression)
Significant variability in addressing co-morbidity and guideline adherence
No specific tools to implement patient-centered care
Applications: 2 hypothetical patients
Patient 1 (all 5 conditions)
11 drugs required ( additional 10 recommended)
make 9 self-care or lifestyle changes
attend 8-10 appointments multiple appointments for counseling and rehabilitation
Patient 2 (DM and COPD) - recommendations
5 medications (up to 8 more recommended)
make 6 self-care or lifestyle changes
5-8 primary care visits and multiple appointments for counseling and rehabilitation
Hughes LD et al, Age Aging 2013

Less predictable
Less common
Not dose dependent
Type A ADRs - dose-dependent
Type B ADRs ("allergic"/hypersensitivity or idiosyncratic)
Prescribing cascade
A new drug is prescribed to treat symptoms arising from an unrecognized ADE related to an existing therapy
Risk for developing additional ADEs
Rochon PA, BMJ 1997
Stiffness, shuffled gait,
tremor, falls
Impaired cognition
80 y/o Male admitted
with pelvic fracture
PRESCRIBING
CASCADE
Pain
Rx: acetaminophen, narcotics
Nausea
Rx: dimenhydrinate
Confusion
Agitation
Rx: anti-psychotics
Rx: antiparkinson
therapy
Falls
Cognitive impairment
Weight loss
Ongoing nausea
Polypharmacy
AGS Geriatric Review Syllabus, 7 edition
th
th
AGS Geriatric Review Syllabus, 7 edition
Pharmacodynamics
Risk Factors for ADEs in Elderly
Suboptimal therapy for chronic conditions
Admissions to hospital
Delirium
Impaired mobility
Falls
Other
CHF exacerbations
HTN
DM
Dementia
Urinary incontinence
Renal impairment
Accelerated cognitive decline
Weight loss

Anti-cholinergics
Dopamine agonists
Antihistamines
Antidepressants
Anti-emetics
Anti-psychotics
Sedatives
Narcotics
Herbal preparations
Always include "drugs" in the differential diagnosis
22 evidenced-based prescribing indications categorized by organ system
Barry PJ et al, Age and Aging 2008
Failure to prescribe appropriate medicines is a highly prevalent problem among older people presenting to hospital with acute illness
The most common prescribing omissions:
Statins in atherosclerotic disease (26%)
Warfarin in chronic atrial fibrillation (9.5%)
Anti-platelet therapy in arterial disease (7.3%)
Calcium/Vitamin D supplementation in symptomatic osteoporosis (6%).
Increase awareness of medications that may increase
the risks of ADRs

Complete list available on the American Geriatric
Society website (www.americangeriatrics.org)

Pocket cards from: www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf
Potentially inappropriate medications for the elderly (PIM)

The Beers Criteria identify 34 such inappropriate drugs, where potential risks exceed benefits

Criteria apply to patients over 65, regardless of level of frailty
BEERS Criteria for Inappropriate Medication Use in the Elderly

Captures more PIMs than Beer's criteria in acutely ill elderly
Thiazide diuretic with history of gout
β-blocker in COPD or diabetes with frequent hypoglycemia
Imodium or codeine phosphate for treating diarrhea of unknown cause
NSAIDs with heart failure, moderate to severe HTN, CRF
Benzodiazepines, antipsychotics, vasodilators causing
postural hypotension, or long term opiates in recurrent falls
Antidepressants and anticholinergic agents in
bladder outlet obstruction (eg BPH)
Any TCA in patients with dementia, glaucoma, cardiac blocks,
or constipation
STOPP Criteria
Gallagher P. et al, Age and Aging 2008
AGS Geriatric Review Syllabus, 7th edition
AGS Geriatric Review Syllabus, 7th edition
AGS Geriatric Review Syllabus, 7th edition
AGS Geriatric Review Syllabus, 7th edition
AGS Geriatric Review Syllabus, 7th edition
Summary
Medication reconciliation
Prescriptions
OCTs meds
Alternative medicine remedies
Adherence
Include ADEs/ADIs in the Ddx
Estimate CrCl
Consider serum drug levels
Admission
Medication reconciliation and patient education
Strategies to enhance adherence
Communication with primary care provider regarding changes and need for follow-up
Discharge
Community
ER
New meds
"Start low, go slow"
BEERS, START criteria
Review periodically list of medications
Which meds can be stopped, decreased or substituted?
BEERS, STOPP criteria
Any ADEs/ADIs?
Consult clinical pharmacist
Communication, communication, communication....
Periodic evaluation of list of medications
- Is there an indication for the drug?
- Is the dosage correct?
- Are the directions correct?
- Are the directions practical?
- Are there clinically significant drug-drug
interaction?
- Is the duration of therapy acceptable?
- Unnecessary duplication with other drugs?
Patient's education to enhance adherance
Community clinical pharmacist
Are there any questions
or suggestions?

Increased hospitalization rates for elderly due to inappropriate use compared to yonger adults
Jano E, Ann Pharmacotherapy 2007
Budnitz DS, Ann Intern Med 2007
Orthostatic hypotension
Antihypertensives
Neuroleptics
BZDs
Antidepressants
EPS
Age > 85 yr
Low BMI
>6 concurrent diagnosis
Estimated CrCl < 50 mL/min
> 9 medications
> 12 doses/day
Prior ADE
Full transcript