PolypharmacyJillian Hernan Fee, PharmD, BCPS

Clinical PharmacistCarePro Home Infusion

April 25, 2014

Polypharmacy, what is it?

• Poly (Greek) = Many

• Pharmacy = Drugs/Medications

• What does many drugs mean?– How many meds are too many?

• Example 1 – 75 yom with CHF, CAD, DM, HTN, HLP

• Example 2 – 82 yof with dementia and overactive bladder

CarePro Pharmacist Poll

• Using multiple pharmacies, providers, and prescription drugs that may not be appropriately monitored (3)

• Using multiple medications either for same condition or to treat side effects of another drug (7)

• Using multiple medications that are not clinically indicated (1)

• Unnecessary use of meds when fewer meds or other options may be more appropriate (1)

• Using more than one pharmacy to fill rx meds (may be drug seeking behavior)

• Using more than 5-7 medications (4)– Number of meds changed with RPh

Polypharmacy definition

Bushardt 2008

Polypharmacy definition• Most common in literature:

– Medication does not match diagnosis (4)– Many medications, duplication of medications, drug-drug

interactions (3)– Inappropriate dosing frequency (excessive duration, dose

too low, dose too high), medication prescribed to treat a side effect (2)

– The term “inappropriate” often occurs in definitions– Number of medications taken routinely

• “Hyperpharmacotherapy”– Excessive use of drugs for treatment of disease

• Not really used mainstream but I like this term• Carries a negative connotation

• Medication Underutilization– Omission of an indicated and potentially beneficial

medication for the treatment or prevention of diseaseBushardt 2008, Barry 2007, Wright 2009

Consequences of polypharmacy

• CMS estimates $50 billion annually

• Adverse drug reactions– Risk increases with multiple comorbidities,

use of high risk drugs (ie warfarin), and increasing numbers of meds

• Adherence– ADR’s– Complex regimens

Bushardt 2008, Hajjar 2007

Consequences of polypharmacy

• Inappropriate prescribing– More meds = higher risk – Beers’ list meds– Drug interactions– Is the medication list complete and correct?

• Geriatric Syndromes– Increased risk of cognitive impairment– Increased risk of falls

• Morbidity/Mortality

Hajjar 2007, Agostini 2004

Who is at risk?

Kaufman 2002

Who is at risk?

Kaufman 2002

Who is at risk?

• Demographic– Age, caucasian race, education

• Health status– Poorer health, use of >8 medications– Diagnosis of: HTN, anemia, asthma, angina, diverticulitis,

arthritis, gout, DM• Access to health care

– Multiple providers, number of health care visits, supplemental insurance

• Underutilization– Increased severity of comorbid conditions– Physical limitations– Caucasian race

Hajjar 2007, Wright 2009

Why elderly?

• Physiological changes– Decreased renal function– Decreased hepatic function– Decreased total body water and lean body

mass– Decreased vision/hearing

• Lack of clinical trials in elderly patients

Bushardt 2008

Prevalence of polypharmacy

• Steinman 2006– Evaluated 196 patients taking 1,582

medications– 65% of patients were taking one or more

inappropriate meds– 64% missing beneficial meds– 42% taking inappropriate meds AND were

missing beneficial meds– 13% had appropriate therapy!!

Prevalence of polypharmacy

• Hajjar 2005– 384 frail, elderly patients’ medication

regimens evaluated at hospital discharge– 44% had at least one unnecessary drug

• Almost 75% of these patients were on this unneeded drug prior to hospitalization

– 18% had 2 or more inappropriate meds

Prevalence of underutilization

• Wright 2009– 384 frail, elderly patients’ medication

regimens evaluated at hospital discharge– 62% (238 patients) were missing a potentially

beneficial medications• 87.3% of these patients were missing this drug

prior to hospitalization

– 25.8% (99 patients) were missing 2 or more medications

Assessments

• Beers’ List• Medication Appropriateness Index• STOPP

– Screening Tool of Older Persons’ potentially inappropriate Prescriptions

• Hyperpharmacotherapy Assessment Tool• START

– Screening Tool to Alert doctors to the Right Treatment

• Assessment of Underutilization Index• Geriatric Evaluation

Beers’ List

• Originally pusblished in 1991 for residents of nursing homes

• Lists of medication considered potentially inappropriate medications in elderly patients1. Drugs to avoid in elderly2. Drugs to avoid in elderly with certain disease states3. Drugs to be used with caution in the elderly

• Intended as a guideline only, using these meds in elderly is not automatically inappropriate

• See handout

Fick 2012

Beers’ List

• Notable 2012 changes– Medications/classes to avoid

• Glyburide, megestrol, sliding scale insulin

– Medications/classes to avoid in certain disease states

• Heart failure – thiazolidinediones (glitazones)• History of syncope – acetylcholinesterase inhibitors• Falls/fractures – SSRI’s

– Medications/classes to use with caution• Prasugrel (Effient), Dabigatran (Pradaxa)

– Greater risk of bleeding in the elderly

Fick 2012

Medication Appropriateness Index

• Evaluates each medication individually based on 10 criteria for appropriateness

• Limitations:– Time (10 minutes/drug)– Full scope of ADR’s not included

• Assesses drug-drug or drug-disease interactions but not side effects independently

– Adherence is not addressed

Hanlon 1992

Hanlon 1992

Summated MAI

• Attempted to quantify the level of inappropriateness

• Grouped questions in MAI by level of importance– Group A: indication and effectiveness– Group B: dosage, correct directions, drug-drug

and drug-disease interactions– Group C: practical directions, expense,

duplication, and duration

• Limitations – same as for MAI

Samsa 1994

STOPP

• Screening Tool of Older Persons’ potentially inappropriate Prescriptions

• Developed in Europe

• Potentially inappropriate medications are listed by organ system– Focused on meds commonly used in geriatric

population in Europe

• See handout

Gallagher 2008 (Clin Pharmacol Ther)

Hyperpharmacotherapy Assessment Tool

• Suggest annual review (at minimum)• Form is set up based on various goals

– I. Number of meds– II. Decrease inappropriate meds

• Meeting goals, disease still present?, least expensive option, Beers List med?

– III. Decrease inappropriate pharmacology• Duplications, combo meds, ADR’s, interactions

– IV. Optimize dosing regimen• Is this is the lowest effective dose? Any meds taken more than

BID? Adherence issues?– V. Organize sources of meds

• More than one pharmacy? Mail order? Other prescribers?– VI. Patient education

Bushardt 2008

Assessment of Underutilization

Jeffery 1999

START

• Screening Tool to Alert doctors to the Right Treatment

• Developed in conjunction with STOPP guidelines in Europe

• Meds are screened by organ system

• See handout

Gallagher 2008 (Clin Pharmacol Ther)

Specialized Geriatric Evaluation

• Integrated team of geriatricians, social workers, nurses, and other healthcare providers evaluate medication use in both inpatient and outpatient setting

• Study done at several VA centers– Assessed 834 frail, elderly veterans for adverse drug

reactions and suboptimal prescribing in both outpatient clinics and as inpatients compared with usual care

– Primary outcome: adverse drug reactions• Both any ADR and serious ADR’s were assessed

– Results: outpatient clinics but not inpatient units reduced the risk of serious ADR’s

Schmader 2004

How well do evaluations work?

• Gallagher 2011– Evaluated 382 patients randomized to usual care or

evaluation with STOPP/START criteria from hospital admission to 6 months after discharge

– Primary outcomes: change in MAI and AOU scores– Results

• MAI – 71.1% of intervention and 35.4% of control group had improved MAI score on hospital discharge

– Absolute risk reduction 35.7%– Number needed to screen: 2.8 (95%CI 2.2-3.8)

• AOU – 31.6% of intervention and 10.4% of control group had a reduction in AOU score on hospital discharge

– Absolute risk reduction 21.2%– Number needed to screen: 4.7 (95%CI 3.4-7.5)

– The rate of potentially inappropriate prescribing increased gradually during the 6 month follow up period – authors conclude that patients should be assessed at least every 6 months

How well to evaluations work?

• STOPP vs Beers’ List– Evaluated 715 admissions of elderly patients– Trained clinicians identified patients who’s admission

were due to adverse effects• The number of potentially inappropriate meds identified by

the 2 evaluations were compared

– Results• All drugs

– STOPP: found inappropriate meds in 35% of patients– Beers’ List: found inappropriate meds in 25% of patients

• Admissions due to ADR’s (N=90)– STOPP: identified 91% (82 pts) of the meds as inappropriate– Beers’s List: identified 48% (43 pts) of the meds as inappropriate

Gallagher 2008 (Age and Ageing)

How to appropriately stop meds

• Do not stop more than 1 drug at a time– Some meds require tapering off and careful

monitoring during the taper period– Attempt to make changes over a longer

period of time

• Consider use of midlevel practioners for follow up visits and monitoring

Bushardt 2008

Role of the dietician

• Grapefruit interactions

• Ask patient what their meds are for

• Remind patients– Take med list to every provider visit– Update the list with every visit– Tell all providers about all meds, including

OTC and herbal meds

Agostini JV, Han L, Tinetti ME. The relationship between number of medications and weight loss or impaired balance in older adults. J Am Geriatr Soc. 2004;52:1719-1723.

Barry PJ, Gallagher CR, O’Mahony D. START (screening tool to alert doctors to the right treatment)- an evidence based screening tool to detect prescribing omissions in the elderly. Age Ageing. 2007;36:632-638.

Bushardt RL, Massey EB, Simpson TW, et al. Polypharmacy: misleading, but manageable. Clin Int Aging. 2008:3(2) 383-389.

Fick D, Semla T, Beizer J, et al. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631.

Gallagher PF, O’Connor MN, O’Mahony. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharm Ther. 2011;89(6):845-854.

Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age and Ageing. 2008;37:673-679.

Gallagher P, Ryan C, Kennedy J, et al. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) and START (Screening Tool to Alert doctors to the Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72-83.

Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5:345-351.

Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatri Soc. 2005;53:1518-1523.

Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045-1051.

Jeffery S, Ruby C, Twersky J, et al. Effect of an interdisciplinary team on suboptimal prescribing in a long-term care facility. Cons Pharm. 1999;14:1386-1391.

Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of medication use in the ambulatory adult population of the United States: The Slone Survey. JAMA. 2002;287:337-344.

Samsa GP, Hanlon JT, Schmader KT, et al. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol. 1994;47(8):891-896.

Schmader KE, Hanlon JT, Pieper CF, et al. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med. 2004;116:394-401.

Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc. 2006;54:1516-1523.

Wright RM, Sloane R, Pieper CF, et al. Underuse of indicated medications among physically frail older US veterans at the time of discharge: results of a cross-sectional analysis of data from the geriatric evaluation and management drug study. Am J Geriatr Pharmacother. 2009;7:271-280.