Tag: polypharmacy

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Deprescribing

As part of the medication review, pharmacist should also be assessing patients for polypharmacy. While polypharmacy is often associated with the elderly, it can also be found in younger patients with multiple comorbidities, sick children, low literacy patients and patients with diminished capacity. Address polypharmacy by deprescribing.
Deprescribing is the process of identifying and stopping medications that are unnecessary, ineffective, and/or inappropriate. Reducing polypharmacy improves health outcomes. Deprescribing is a process that weighs the benefits vs. harms of medications. This process considers patient’s care goals, current level of functioning, life expectancy, values, and preferences.

Polypharmacy is associated with multiple medications, four or more. Negative consequences include:

• an increased risk for adverse drug events (ADEs)
• drug-drug and drug-disease interactions
• reduced functional capacity
• multiple geriatric syndromes
• medication non-adherence
• increased mortality
• Polypharmacy also contributes to increased health care costs for both the patient and the health care system
Polypharmacy often results from prescribing cascades, which occur when an adverse drug effect is misinterpreted as a new medical problem, leading to the prescribing of more medication to treat the initial drug induced symptom.

Safe and Effective deprescribing strategies

Deprescribing process constitutes:

Starting the deprescribing process:

1. Review all current medications: include prescription, over the-counter (OTC), and complementary/alternative medicine (CAM) agents.
a. Consider the potential benefits and harms of each medication.
b. Assess whether the patient is taking all medications prescribed
c. identify any reasons for missed pills (e.g. adverse effects, dosing regimens, understanding, cognitive issues).

2. Talk about stopping some medications with the patient:
a. risks and benefits of deprescribing
b. prioritize which medications to address in the process. Prioritize the medications by balancing patient preferences known benefit.
c. Stop medications lacking evidence supporting the benefits
d. consider known or suspected adverse effects
e. consider decreasing pill burden
f. consider the patient’s preferences and goals of care
g. remaining life expectancy
h. time until drug benefit is obtained
i. length of drug benefit after discontinuation.

3. Deprescribe: when tapering a medication develop a schedule in partnership with the patient. Stop one medication at a time and monitor for withdrawal symptoms or for the return of a condition.

Potential Barriers to deprescribing

Patient barriers include: fear of a condition worsening, lack of support to manage condition, previous bad experience with stopping medication, and influence from other care providers (e.g., family, nurses, specialists). Using a team-based and stepwise patient approach to deprescribing aims to provide patients with appropriate education and support to begin to reduce unnecessary medicines.

Provider barriers include feeling uneasy about contradicting a specialist’s recommendations for initiation/continuation of specific medications, fear of causing withdrawal symptoms or disease relapse, lack of specific data to adequately understand and assess benefits and harms in the older adult population. Primary care physicians acknowledged worry about discussing life expectancy and that patients will feel their care is being reduced. Often there is limited time to discussed complex shared decision-making conversations. One way to overcome some of these concerns is to consider working with a clinical pharmacist. Pharmacist can help with Information regarding medication-specific factors, such as half-life and expected withdrawal patterns, can help the decision to deprescribe or not. Close communication with specialists, allows for discussions regarding medication concerns like adverse effects, limited benefits, or compliance. It will allow the development of a collaborative, cohesive, and patient-centered plan to deprescribe.

4. Follow up plan: develop a for monitoring and assessment. Patient should be told symptoms may occur in the event of drug withdrawal and which symptoms may suggest the return of a condition. Supports should be in place if needed (e.g., physical therapy, social support) to help ensure success.

The object is to improve outcomes, decrease risks for drug interactions and adverse effects. Keeping these goals in mind individualize each plan for each patient.

Reerences:

  1. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults.  J Am Geriatr Soc. 2015;63:2227-2246.
  2. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44:213-218. Orwig D, Brandt N, Gruber-Baldini AL. Medication management assessment for older adults in the community. Gerontologist. 2006;46:661-668.
  3. Anderson K, Jue SG, Madaras-Kelly KJ. Identifying patients at risk for medication mismanagement: using cognitive screens to predict a patient’s accuracy in filling a pillbox. Consult Pharm. 2008;23:459-472.
  4. Lenaerts E, De Knijf F, Schoenmakers B. Appropriate prescribing for older people: a new tool for the general practitioner. J Frailty & Aging. 2013;2:8-14.
  5. https://www.mdedge.com/sites/default/files/Document/June-2017/JFP06607436.PDF

 

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Polypharmacy

Polypharmacy, or the use of multiple medications to treat a patient, has negative connotations. When it comes to medications more doesn’t mean better. What is polypharmacy? The definition of polypharmacy varies and as concluded by What is polypharmacy? A systematic review of definitions article, there is no consensus definition for polypharmacy.

Polypharmacy is more common in patients with multiple co-morbidities and is associated with the use of multiple medicines. Polypharmacy refers to the use of many medications, commonly considered the use of five or more medications. Since polypharmacy is a consequence of having several underlying medical conditions, it is much more common in elderly patients. An estimated 30 to 40 percent of elderly patients take five or more medications.

Taking multiple medications, whether prescription drugs, OTC treatments, herbal or dietary supplements; is a burden for patients and it can be dangerous. Dangers such as unwanted drug interactions and decrease drug adherence to essential medicines.

In the longitudinal study: Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011, found that 35.8% of adults in the United States were taking five or more medicines. Adverse drug events in ambulatory care, New England Journal of Medicine 2003; 348:1556–1564, a landmark study of adults receiving one or more prescriptions from their primary care physician.

The authors found that 25% of patients had an adverse drug reaction within three months of starting their prescriptions. While 39% of these were preventable errors, most were the result of inappropriate drugs or drug interactions. polypharmacy is the use of more medications than are clinically indicated, representing unnecessary drug use.

What are the reasons for polypharmacy?

• Many co-existing medical conditions. In the case of diseases such as heart failure and high blood pressure, combinations of two to three different medications are common and recommended.
• Medications added for symptomatic relief, medications prescribed to treat adverse effects of another drug.
• Seeing different physicians and being under the care of several specialists.
• Lack of documentation on the use of a medication is often missing in the medical record, making decisions to consider termination of treatment difficult to make later.

What are the consequences of polypharmacy?

The major consequence of polypharmacy to a patient is a much higher risk of adverse drug effects. Risk increases based on the number of medications prescribed and taken.

Adverse drug effects often require physician visits, emergency room visits or hospitalizations. It can be difficult figuring out which medication is causing the adverse effect, avoiding drug interactions and improving adherence.

Adverse drug events WHO: “Unintended and undesired effects of a medication at a normal dose”:
• Adverse Drug Reaction
• Medication Error
• Therapeutic Failure
• Adverse Drug Withdrawal Event
• Overdose

Polypharmacy makes it hard for the patients to remember when and how to take all prescribed medications. Multiple medications increase the risks of inappropriate medication use, non-adherence, adverse effects, and medical cost.

Physicians may hesitate to prescribe a new essential medication to a patient already on four or more medications. Polypharmacy can lead to under treatment.

Another consequence of overutilization is the soaring cost of health care in 2015, the U.S. spent $325 billion on retail prescription drugs (drugs purchased at pharmacies and through the mail), almost twice that of other developed countries. Higher expenditures can be justified if the health outcomes for U.S. patients measured as life expectancy, disease-specific mortality and other measures were more favorable but they are not.

Potentially inappropriate prescribing defined:

• Risk > Benefit
• Over‐prescribing
• Excessive doses/duration of medicines
• Polypharmacy
• Mis-prescribing Unfavorable choice of medicine, dose, or duration
• Under‐prescribing Not prescribing a clinically indicated medicine, despite the patient not having any contra‐indication to that medicine

Preventing and Reducing Polypharmacy

We strongly recommend medication review by a Pharmacist for patients prescribed a large number of medications. Other recommendations:

1) Primary care physician needs to coordinate the use of multiple medications.

2) Potentially Inappropriate Medications (PIMs):
Medications that pose more risks than benefits to older adults by themselves and considering the availability of alternative treatments.

3) Instead of adding a new medication to treat an unwanted side effect, stopping or changing the dose of the offending drug would solve the problem.

4) Medications lacking an indication, medications with limited value or are therapeutic duplication should be discontinued.

5) Always consider a new symptom as possible drug-induced (review chronology of medications)

6) Consider stopping/tapering medications

7) Consider reducing dose with age

8) Do a drug interaction check

9) Review the goals of care and treatment targets

10) Prescribe strategically (e.g. reduce pill burden, simplify regimen, use meds for more than one purpose)

Pearls for Decreasing Polypharmacy:

• Start low and go slow
• Don’t set it and forget it (PK)
• Ask about herbs, roots, nuts, berries
• Trust but verify
• Avoid narrow therapeutic index meds
• Review medication lists regularly
• Avoid too many changes at one time
• Begin with the end in mind
• Utilize Beers or START/STOP criteria for regular assessment

Decreasing medication use in the elderly can reduce adverse events (e.g. falls, hospitalizations), reduce pill burden and costs, increase adherence with remaining medications, Improve the quality of life. Patients, family members, and caretakers should be educated on the dangers of polypharmacy. for more information on patient education, see JAMA’s patient’s page on Polypharmacy.

Pharmacists, in general, are in the best position to help patients with polypharmacy. Ambulatory care pharmacists routinely see patients and should be conducted not only routine medication adherence but review for polypharmacy.