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Geriatric Polypharmacy, The Good The Bad And The Ugly

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Geriatric Polypharmacy, The Good The Bad And The Ugly John Kashani DO Staff Toxicologist, New Jersey Poison Center Attending, St. Joseph s Regional Medical Center – PowerPoint PPT presentation

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Title: Geriatric Polypharmacy, The Good The Bad And The Ugly


1
Geriatric Polypharmacy, The Good The Bad And The
Ugly
  • John Kashani DO
  • Staff Toxicologist, New Jersey Poison Center
  • Attending, St. Josephs Regional Medical Center

2
Objectives
  • Discuss the epidemiology of the aging population
  • Discuss polypharmacy and adverse drug reactions
  • Outline pharmacokinetics as it relates to the
    aging population

3
Objectives
  • Outline potentially inappropriate medications for
    the elderly population
  • Discuss clinically significant drug interactions
  • Provide a rational approach to elderly medication
    prescribing
  • Illustrate polypharmacy cases

4
Introduction
  • Over 30 new medications are introduced each year
  • Recognizing drug interactions is a daily
    challenge and is becoming increasingly more
    difficult
  • Multiple drug regimes carry the risk of adverse
    interactions

5
Introduction
  • Precipitant drugs modify the object drugs
    absorption, distribution, metabolism, excretion
    or clinical effect
  • Additionally, newly introduced medications, and
    medications with new indications may have
    multiple pharmacologic effects

6
Introduction
  • The population is steadily aging
  • Greater than 65 years old
  • 12 of the United States Population
  • 43 of Emergency Department
  • 48 of critical care admissions

7
Introduction
  • 2003 Poison Center exposures
  • Increases fatality ratio
  • Greatest among those 80 years or older
  • May be grossly underestimated

8
Introduction
  • The elderly are prescribed more drugs
  • 32 of prescriptions
  • Cardiovascular disease
  • Arthritis
  • Gastrointestinal disorders
  • Bladder dysfunction

9
Introduction
  • Average use for persons 65 years or older
  • 2 to 6 prescription drugs and 1 to 3.4
    over-the-counter medicines
  • Average American senior spends 670/year for
    pharmaceuticals

10
Polypharmacy
  • Polypharmacy means "many drugs
  • The use of more medication than is clinically
    indicated or warranted
  • 5 or more drugs

11
Adverse Drug Reaction
  • The most consistent risk factor for adverse drug
    reactions (ADRs) is the number of drugs being
    taken
  • Risk rises exponentially as the number of drugs
    increases

12
Adverse Drug Reaction
  • ADRs occur as a result of
  • Drug-drug interactions
  • Drug-disease interactions
  • Drug-food interactions
  • Drug side effects
  • Drug toxicity

13
Polypharmacy
  • Polypharmacy leads to
  • More adverse drug reactions
  • Patient outcomes
  • Poor quality of life
  • High rate of symptomatology
  • (Unnecessary) drug exposure/expense

14
Consequences Quality of Life
  • In ambulatory elderly 35 experience ADRs and
    29 require medical intervention
  • In nursing facilities 2/3 of residents
    experience ADRs
  • Up to 30 of elderly hospital admissions involve
    ADRs
  • Beers MH. Arch Internal Med.
    2003

15
  • If medication related problems were ranked as a
    disease, it would be the fifth leading cause of
    death in the US!
  • Beers MH. Arch Internal Med. 2003

16
Pharmacokinetics and Aging
  • Absorption
  • Distribution
  • Metabolism
  • Excretion

17
Pharmacokinetics and Aging
  • Absorption
  • Age-related gastrointestinal tract and skin
    changes seem to be of minor clinical significance
    for medication usage

18
Pharmacokinetics and Aging
  • Distribution
  • Important Age-Related Changes
  • Decrease in Lean Body Mass and total body water
  • Increased percentage Body Fat

19
Pharmacokinetics and Aging
  • Increase in volume of distribution for lipophilic
    drugs
  • Protein Binding changes are of modest
    significance for most drugs, especially at
    steady-state

20
  • Volume of distribution (Vd)
  • Apparent volume the drug is dissolved in
  • Measured in Liters or Liters/Kg
  • not a real volume

21
Pharmacokinetics and Aging
  • Metabolism
  • Though liver function tests are unchanged with
    age, there is some overall decline in metabolic
    capacity
  • Decreased liver mass and hepatic blood flow

22
Pharmacokinetics and Aging
  • Hepatic conjugation
  • Inactive metabolites
  • Hepatic oxidation
  • Active metabolites

23
Pharmacokinetics and Aging
  • Renal Excretion
  • Age-related decreased renal blood flow and GFR is
    well-established
  • Decreased lean body mass leads to decreased
    creatinine production

24
Pharmacokinetics and Aging
  • Cr clearance(140-age)(IBW)/creatinine(72)
  • (multiply by 0.85 for women)
  • Example 70kg 75 year old man
  • Cr Clearance (140-75)(70)/1.0(72)63

25
Pharmacodynamics and Aging
  • Generally, lower drug doses are required to
    achieve the same effect with advancing age
  • Receptor numbers, affinity, or post-receptor
    cellular effects may change
  • Changes in homeostatic mechanisms can increase or
    decrease drug sensitivity

26
Avoiding Polypharmamcy
  • Avoid automatic refills
  • Look for other sources of medications ie. OTC
  • Caution with multiple providers
  • Dont use medications to treat side effects of
    other meds
  • What can you discontinue or substitute for safer
    medication?

27
Vitamin and Herbal Use in Older Adults
  • Highly prevalent among older adults
  • Generally not reported to the physician
  • Some serious drug interactions are possible
  • Warfarin gingko biloba, vitamin E
  • SSRIs St. Johns Wort

28
(Potentially)Inappropriate Medications for Older
Adults
  • Propoxephene
  • Diphenhydramine
  • Amitryptiline
  • Alprazolam
  • Diazepam
  • Beers, MH et al. Arch Intern Med
    1511825,1991.

29
Polypharmacy in the Making
  • Drug reactions in the elderly often produce
    effects that simulate the conventional image of
    growing old
  • unsteadiness drowsiness
  • dizziness falls
  • confusion depression
  • nervousness incontinence
  • fatigue malaise
  • insomnia

30
Polypharmacy in the Making
  • Avoid treating adverse reactions/side effects of
    drug with more drugs!
  • Dizziness from anti-hypertensive treated with
    meclizine
  • Edema from a calcium-channel blocker treated with
    furosemide and KCL

31
Polypharmacy in the Making
  • Drugs most frequently associated with adverse
    reactions in the elderly
  • psychotropic drugs
  • anti-hypertensive agents
  • diuretics
  • digoxin

32
Polypharmacy in the Making
  • NSAIDS
  • corticosteroids
  • warfarin
  • theophylline

33
Warfarin
  • Drugs that inhibit warfarin's metabolism include
    ciprofloxacin (Cipro), clarithromycin (Biaxin),
    erythromycin, metronidazole (Flagyl) and
    trimethoprim-sulfamethoxazole (Bactrim, Septra)
  • Acetaminophen

34
Warfarin
  • Aspirin
  • Nonsteroidal Anti-inflammatory Drugs

35
Fluoroquinolones
  • Divalent cations (calcium and magnesium) and
    trivalent cations (aluminum and ferrous sulfate)

36
Antiepileptic Drugs
  • Carbamazepine (Tegretol), phenobarbital and
    phenytoin (Dilantin)
  • CYP450 interactions

37
2D6/3A4
  • Fluoxetine (Prozac)Paroxetine (Paxil)Sertraline
    (Zoloft)
  • Cimetidine (Tagamet)Clarithromycin
    (Biaxin)ErythromycinFluvoxamine
    (Luvox)Grapefruit juiceItraconazole
    (Sporanox)Ketoconazole (Nizoral)Lovastatin
    (Mevacor)Nefazodone (Serzone)Cisapride
    (Propulsid)

38
Lithium
  • Diuretics
  • Ace Inhibitors
  • NSAIDS

39
Sildenafil
  • Nitrates

40
3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase
Inhibitors
  • Concomitant use of statins and erythromycin,
    itraconazole, niacin or gemfibrozil (Lopid) can
    cause toxicity that manifests as elevated serum
    transaminase levels, myopathy, rhabdomyolysis and
    acute renal failure

41
Serotonergic Agents
  • Inhibit 5-HT uptake
  • Enhances 5-HT release
  • Inhibits 5-HT breakdown
  • Metabolized to 5-HT
  • 5-HT1A agonist
  • Enhances 5-HT receptor response to stimulation

42
Case 1
  • 80 year old widow who now lives with her
  • daughter comes to Emergency Department
  • complaining of being a nervous wreck and
  • not being able to turn off her mind
  • for the past 2 yrs. She brings with her a bag
  • of all her meds

43
Case 1
  • PMHx CHF, irritable bowel syndrome,
  • depression, HTN, recurrent UTIs, stress
  • incontinence, anemia, occipital
  • headaches, osteoarthritis, generalized
  • weakness

44
Case 1
  • Meds sucralfate, Cimetidine, enteric
  • ASA, Atenolol, Digoxin, Alprazolam,
  • Naproxen, Oxybutynin, Dicyclomine TID,
  • Lasix, Tylenol 2, Verapramil

45
Medication Red Flags
  • High risk drugs alprazolam, oxybutynin, tylenol
    2, dicyclomine, NSAIDS
  • Digoxin

46
P-Glycoproteins, Digoxin and polypharmacy
Small Intestine
Biliary Excretion


Bile
Hepatocyte
Plasma
Lumen
Enterocyte
Plasma
Renal Tubular Secretion

Urine
Tubular Cell
Plasma
47
P-Glycoproteins
  • Inhibitors
  • Amiodarone
  • Clarithromycin
  • Cyclosporine
  • Diltiazem
  • Erythromycin
  • Ketocanazole
  • Quinidine
  • Verapramil
  • tacrolimus
  • Inducers
  • Rifampin
  • St. Johns Wort
  • Dexamethasone
  • Indinavir
  • Ritonavir
  • Retonoic acid
  • Morphine
  • Phenothiazine
  • clotrimazole

48
Medication Red Flags
  • naproxen and aspirin carry the potential drug
    related adverse events of gastritis/GIB and
    sucralfate and cimetidine are being used to treat
    these side effects

49
Case 2
  • Mrs. Jones is a 72 yr living in an assisted
  • living facility where she has been recently
  • complaining of increasing confusion,
  • lightheadedness in the am and difficulty
  • sleeping at night

50
Case 2
  • PMHx CHF, NIDDM, OA, glaucoma,
  • depression, and stress incontinence
  • Meds Digoxin, Furosemide, Timolol gtts,
  • Metformin, Ibuprofen, Paroxetine,
  • Oxybutynin,Propoxyphene/apapprn, and
  • Diphenhydramine

51
Medication Red Flags
  • Diphenhydramine sedative, anticholinergic
    properties
  • Oxybutynin anticholinergic Propoxyphene -
    narcotic
  • Digoxin

52
Case 3
  • Mr. Wilson is a 81 yr who had an URI and
  • subsequently was admitted for acute
  • confusion and disorientation. He then
  • began wandering and having
  • hallucinations while spiking a fever.

53
Case 3
  • PMHx CAD with MI, COPD, DJD,
  • Hypothyroidism, Depression/anxiety,
  • chronic anemia and diarrhea, aortic valve
  • replacement, gout, neuropathy, bilateral
  • total knee replacements

54
Case 3
  • Meds aggrenox, neurontin, theophylline,
    synthroid, allopurinol, prozac, combivent,
    colchicine, Imodium prn, metamucil, calcium,
    iron, multivitamin, codeine

55
Case 3
  • Medical workup significant for negative head CT,
    EKG with no acute changes, UA, CBC, LP, Chem10,
    CXR shows possible RLL infiltrate

56
Medication Red Flags
  • Theophylline low therapeutic index
  • Iron deficiency anemia is more rare in men, so
    check levels and maybe discontinue supplement
  • Chronic diarrhea iatrogenic? From colchicine?
    Also Imodium is anticholinergic

57
Prescribing Pearls
  • Use single daily dose regimens
  • Limit the use of PRN medications
  • Consider all new medicines as a therapeutic trial

58
Prescribing Pearls
  • Discontinue a drug if it is ineffective or
    intolerable adverse effects occur
  • Provide legible written instructions
  • Instruct caregivers as needed

59
Patient Education
  • Use one pharmacist/pharmacy
  • Use your PCP as intendedavoid seeing multiple
    physicians
  • Do not use medications from others
  • Report symptoms
  • All medicines, even over-the-counter, have
    adverse effects
  • Report all products used

60
Ways to Decrease Drug Costs
  • Generics ok
  • Change dosing regimen
  • Older drugs, e.g. beta blockers, diuretics,
    acetaminophen
  • Double duty drugs, e.g. beta and alpha blockers,
    ACE-inhibitors
  • Avoid non-regulated products

61
Geriatric Rx Principles
  • First consider non-drug therapies
  • Match drugs to specific diagnoses
  • Reduce meds when ever possible
  • Avoid using a drug to treat side effects of
    another

62
Geriatric Rx Principles
  • Review meds regularly (at least q3 months)
  • Avoid drugs with similar actions/same class
  • Clearly communicate with pt and caregivers
  • Consider cost of meds!

63
Avoiding Polypharmamcy
  • Avoid automatic refills
  • Look for other sources of medications ie. OTC
  • Caution with multiple providers
  • Dont use medications to treat side effects of
    other meds
  • What can you discontinue or substitute for safer
    medication?

64
Summary
  • Polypharmacy and ADRs have profound medical and
    economic consequences
  • Elderly have unique pharmacokinetics predisposing
    them to drug toxicity
  • High risk medications include cardiovascular,
    analgesic, psychotropics, and meds with a low
    therapeutic index

65
Summary
  • Drug toxicity may be masquerading as an illness
  • Be a patient advocate! It may be you one day

66
References
  • Swansons Family Practice Review. Fourth Ed. A.
    Tallia, D. Cardone, D. Howarth, K Ibsen Mosby
    2001.
  • Geriatrics 20 common problems. A. Adelman, M.
    Daly McGraw Hill 2001.
  • Primary Care Geriatrics A Case- Based Approach.
    Third Ed. R. Ham, P. Sloane Mosby 1997.
  • Essentials of Clinical Geriatrics. Fourth Ed. RL
    Kane, JG Ouslander, IB Abrass McGraw Hill 1999.
  • Polypharmacy. Didactic at SFM by Dr. Pat Borman
  • Holland EG, Degruy FV. Drug- Induced Disorders.
    American Family Physician Vol 56, Nov 1, 1997.
  • Beers MH. Updating the Beers Crieria for
    003Potentially Inappropriate Medication Use in
    Older Adults. Arch Internal Med. 2003 2716-2724.
  • Personal Medical Record developed by Dr. Eric
    Coleman, UCHSC, HCPR http//caretransitions.org/
    document/phr.pdf
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