American College of Physicians - Maine Chapter Autumn Meeting in Bar Harbor September, 2014 Stephanie Nichols, Pharm.D., BCPS, BCPP Associate Professor – Husson University School of Pharmacy Clinical Pharmacist – Psychiatry & Adult Inpatient Medicine Nicholss@Husson.edu Define polypharmacy and recall it's prevalence Illustrate why recognition and management of polypharmacy is important Demonstrate strategies to avoid polypharmacy Assess high risk polypharmacy situations and formulate a plan to initiate pharmacological debridement Employ strategies to improve medication adherence in patients with a high pill burden X+ chronic daily medications? › OTCs/Herbals › Ex. HF or COPD “High Risk Polypharmacy” › Ex. 2+ narcotics, 2+ benzos, 3+ oral hypoglycemics 2+ drugs in the same class? More drugs prescribed than warranted clinically ? › “Prescribing cascade” Kaufman, Kelly, Rosenberg, Anderson, Mitchell. JAMA 2002;287:337-44. Mean number of meds per patient = 13.5 Nearly a quarter had >16 meds OR 4.75 (95% CI: 1.0 – 11.2) for polypharmacy with 2+ high risk diagnoses › COPD, CA, DM, CHF, CAD Rohrer JE et al. J Prim Care Community Health. 2013 Apr 1;4(2):101-5. Gamble JM et al. Therapeutics and Clinical Risk Management 2014:10 189–196 Slabaugh, Maio, Templin, Abouzaid. Drugs & Aging. 2010; 27(12):1019-1028. Viktil GK, Blix HS, Moger TA, Reikvam A. Brit J of Clin Pharmacol 2006;63(2):187-95. Errors › Prescribing › Dispensing › Administration Adverse Reactions Interactions › Drug-Drug Dynamic Kinetic › Drug-Disease Order clarification necessary Duplicate medication/class Medication omission Lack of dose adjustment with AKI or liver failure Low Adherence Falls and Fractures Circulation. 2010; 122:A14790 ED visits and admissions Increased healthcare costs Reduced quality of life Increased mortality Lyles, Culver, Ivester, Potter. Consult Pharm. 2013 Dec;28(12):793-9. Lai, Liao, Liao, Muo, Liu, Sung. Medicine (Baltimore) 2010;89(5):295. 4.2% of admissions due to ADRs Number of Drugs Odds Ratio of ADR Admission 95% CI ≤2 1.0 (Reference) 3-5 5.07 2.71 – 9.59 6–9 5.9 3.16 – 11.0 10 + 8.94 4.73 – 16.89 Pedros C et al. Eur J Clin Pharmacol. 2014 Mar;70(3):361-7. Pedros C et al. Eur J Clin Pharmacol. 2014 Mar;70(3):361-7. Safety Tolerability Effectiveness Price Simplicity Actual assessment Probabilistic of benefits assessment and harms in Only benefit assessed of risk vs benefit on initial Rx an ongoing fashion Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20. 2003 Pocket Card › http://www.americangeriatrics.org/files/doc uments/beers/PrintableBeersPocketCard.pdf AGS iGeriatrics App - $2.99 STOPP - Screening Tool of Older People’s potentially inappropriate Prescriptions › 65 recommendations START - Screening Tool to Alert doctors to the Right Treatment › 22 recommendations http://www.ngna.org/_resources/documentation/ chapter/carolina_mountain/STARTandSTOPP.pdf Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. Int J Clin Pharmacol Ther. 2008 Feb;46(2):72-83. • • • • Rudolph, Salow, Angelini, McGlinchey. Arch Intern Med. 2008;168(5):508. Carnahan, Lund, Perry, Pollock, Culp. J Clin Pharmacol 2006;46:1481-6. Boustani, Campbell, Munger, Maidment, Fox. Aging Health 2008;4:311-20. http://www.indydiscoverynetwork.org/resources/antichol_burden_scale.pdf Find an indication for each drug › Goal of therapy? Are we using the best drug for each problem/disease/disorder in this patient? › Eg. HTN and beta blockers Schedule a “brown bag” appointment periodically When switching from one agent to another, or stopping an agent completely… …ask the community pharmacy to d/c the old prescription Periodically compare medication lists with the pharmacist/pharmacy When new symptoms emerge, particularly in geriatric patients, think about medication AEs http://www.acpm.org/?MedAdherTT_ClinRef http://www.iarx.org/documents/PrinciplesOfHealthcare2010.pdf S implify regimen I mpart knowledge M odify patient beliefs and human behavior P rovide communication and trust L eave the bias E valuate adherence Atreja A, Bellam N, Levy S. Medacapt Gen Med. 2005:7(1): 4. Daily or BID dosing › One-a-day formulations (incl. patches) › Match to ADLs (ex. breakfast) Combination products › Caution: loss of dosing flexibility Treat multiple conditions with one agent › Caution: commonly 2 agents are safer d/c extraneous or unnecessary medications Focus on shared decision making Discuss purposes and side effects of medications Use the teach-back method Employ verbal and written instructions Give contact information for further questions REALM Assessment › http://www.adultmeducation.com/downloa ds/REALMR_INSTR.pdf “As Needed for Water Retention” “Take two every day” Presentation of the advantages and disadvantages of each medication in a way that is understandable to your patient Discuss # of missed doses at each visit, non-punitively Telephone counselling Empathy, supporting self-efficacy, avoiding argumentation, rolling with resistance, and developing discrepancy PSAPs VII; Book 8. Motivational Interviewing. Kavookjian J. Empower patients to self-manage Ask about specific needs, fears, and concerns Identify perceived barriers (ex. financial) Ensure knowledge of the actual risks of missing medications Confirm your patient’s message and paraphrase it Provide empathy and give feedback Involve your patient in decision making Use plain language and confirm understanding Take the time to overcome cultural barriers Tailor education to the appropriate level of complexity for your patient’s optimal understanding Ask direct questions and ask them often › Every visit Identify adherence barriers Recognize lack of perceived benefit 30 day fills on Jan 1st, Feb 7th, Mar 18th, Apr 26th, & June 1st 5 fills * 30d each = 150 days supply Jan 1st – Jun 1st = 151 days + 30 days supply = 181 days 150/181 = 83% MPR Wallet cards – medication lists Pill containers and counting Blister packs Pre-packed kits (ex. Medrol) Textured covers with vision impairment Alarms › On the bottle › Via email Team based care! Consider Long-Acting Injectable Antipsychotics Engage the patient in the treatment decision when able, particularly regarding AEs Ask the pharmacist to partner with the treatment team to alert of non-timely filling Depressed patients are 3x more likely to be non-adherent with medical treatment regimens (non psychotropic) DiMatteo MR, Lepper HS, Croghan TW. Arch Int Med. 2000;160(14):2101. Polypharmacy is prevalent, particularly in those 65+ Polypharmacy increases morbidity, mortality, & healthcare costs, and decreases quality of life Perform ongoing medication assessment with tools, like STEPS, to avoid polypharmacy Use scores, scales, and lists to optimize medication regimens, avoid unnecessary medications, and/or reduce medication burden To improve medication adherence in polypharmacy, simplify the medication regimen and have ongoing dialogue with your patient about risks and benefits of each drug being used Stephanie Nichols, Pharm.D., BCPS, BCPP Associate Professor, Husson University School of Pharmacy Clinical Psychiatric Pharmacist, Maine Medical Center NicholsS@Husson.edu Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20.