Polypharmacy - Strategies, Beers Criteria, & Medications to Avoid | PDF

POLYPHARMACY NURS 6111  Polypharmacy The use or misuse of multiple drugs, both prescription and nonprescription, and their interaction with one another Usually, > 5 medications Multiple causes:  Multiple prescribers for the same patient (think multiple spec...

POLYPHARMACY NURS 6111  Polypharmacy The use or misuse of multiple drugs, both prescription and nonprescription, and their interaction with one another Usually, > 5 medications Multiple causes:  Multiple prescribers for the same patient (think multiple specialists)  Fear of accusation of ageism or cultural bias  Good intentions to treat the side effects of one medication with another  Polypharmacy The elderly population are the biggest consumers of medications Nearly 1/3 of community dwelling adults aged > 65 were taking >5 medications and almost 20% were taking > 10. 42% of older adults take more than one OTC drug 49% take more than one nutritional supplement  Clinical Consequence Polypharmacy is a primary predictor for an adverse drug reaction (ADR) - undesired or unwanted consequence that occurs as a result of taking medications.  Adverse drug events (ADE) - injury resulting from medical intervention related to a drug Increased hospitalization Cognitive and functional decline Prescribing cascades Increased healthcare costs  Physiologic Changes Absorption – decreased gastric acidity Distribution - bioavailability  Decreased body mass and fluid  Decreased cardiac output  Increased body fat  Decreased serum albumin Metabolism  Decreased liver mass and function Elimination  Decreased renal and hepatic function  The most profound pharmacokinetic change is reduced elimination of drugs due to changes in kidney function begin in the fourth decade of life.  Strategies to Improve Polypharmacy Beer’s criteria - a list of potentially inappropriate or harmful medications STOPP – Screening Tool of Older Person’s Prescription  START – Screening Tool to Alert doctors to the RIGHT Treatment  Beer’s Guide Medication Appropriateness Index Criteria:  is there an indication for the drug?  is the medication effective for the condition?  is the dosage correct?  are the directions correct?  are the directions practical?  are there clinically significant drug-drug or drug-disease interactions?  is there unnecessary duplication of meds?  is the duration of therapy acceptable?  is this drug the least expensive and alternative compared with others of equal usefulness?  Beers – Medications to AVOID  Anticholinergics,  Skeletal muscle relaxant  1st gen antihistamines ie.  Non-benzodiazepine sedative diphenhydramine, doxylamine hypnotics ie zolpidiem and hydroxyzine;  sulfonylureas Antiparkinsons agents  Sliding scale  Anti-infective – nitrofurantoin  Pain – NSAIDS (Indomethacin,  Dronedarome (Multaq) Ketoralac); Miperidine  Digoxin  PPI - >8 weeks  Tricyclic Antidepressants  Antipsychotics – 1st and 2nd gen (haloperidol)  Benzodiazepines  STOPP 2 Any drug prescribed without any evidence based clinical indication Any drug beyond recommended duration Any duplicate drug class prescription Recommendations of medications to avoid for each system and alternate medications suggested  Other Strategies in Primary Care “brown bag test”  Encourage elderly patients to bring all meds for each visit so prescriber may assess meds for drug interactions, contraindications, duplications  Include OTC Carry a list of all medications and remind to update  Include the caregiver  Include OTC  Take Home Points The criteria is a list of drugs with the POTENTIAL to cause harm The list is meant to serve as a starting point – not a definitive “DO NOT USE” Weigh risk vs. benefit What’s the REASON for the drug’s place on the list?? Does it apply to your patient?? Consider less risky alternatives if possible  Polypharmacy Strategies for preventing adverse drug reactions and drug-drug interaction  For treatment of the primary disease, chose the drug that is recognized as being the most efficient and safe. Also try to use non-pharmacological treatments first if possible  Drug risk/benefit ratio should be determined  Familiarize with a source of drug-interaction information  Screen for drug-drug interactions when adding a new drug to the regimen  Evaluate renal function and adapt treatment dosing  Do no add a medication to combat the side effect of another drug  Use the least possible number of medications. Try to not start 2 medications at the same time.  Polypharmacy Strategies for preventing adverse drug reactions and drug- drug interactions  Use drugs that have the simplest administration schedule. Use once daily dosing if possible  Screen patients for self medications and OTC medication use  Eliminate PRN meds that have not been used for over 1 month  Print a medication list for the patient  Evaluate cognitive function  Use interdisciplinary approach to managing medications, include family members, caregivers, and pharmacist  Ask patient to recite back medication administration instructions