ELDERLY MEDICATION MANAGEMENT

5/14/2014 ELDERLY MEDICATION MANAGEMENT Jennifer Polzin, PharmD, FCSHP, BCACP, CPhQ SCPMG Regional Outpatient Safety Net Pei Shan Shen, pharmacy int...
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5/14/2014

ELDERLY MEDICATION MANAGEMENT

Jennifer Polzin, PharmD, FCSHP, BCACP, CPhQ SCPMG Regional Outpatient Safety Net Pei Shan Shen, pharmacy intern

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Learning Objective 1. Overview of elderly physiological changes and

drug metabolism 2. Discuss the various medications that are high risks 3. Review alternative medications that replace the current medication which should be avoided

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Baby Boomer are Aging

http://www.aoa.gov/Aging_Statistics/

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As you increase in age.. Body fat Gastric pH Coagulation factors (V, VII, VIII, IX, XIII, fibrinogen) Total body water Lean body mass Serum albumin Cardiac output Maximal breathing capacity Weight & volume of brain GI blood flow & gastric emptying Intestinal transit Liver size & perfusion GFR Renal blood flow & renal mass Plasmin

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PK Alterations in Older Patients • Absorption  Delayed time to onset/peak effects  ↓ effects of subcutaneous administration • Distribution  ↓ Vd for hydrophilic drugs  ↑ Vd for lipophilic drugs  ↓ protein binding • Metabolism  ↓ CYP450 enzyme activity  ↓ hepatic first-pass metabolism  ↓ phase 1 (oxidation) metabolism • Excretion  ↓ clearance  ↑ t1/2 of renally eliminated drugs

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Health Effectiveness Data and Information Set (HEDIS) Measure • HEDIS is a tool used by health plans • Measures performance on different dimensions of

health care • 2014 Medication Measure: Medication Management • Annual Monitoring for Patients on Persistent Medications (MPM) • Medication Reconciliation Post-Discharge (MRP) • Potentially Harmful Drug-Disease Interactions in the Elderly (DDE) • Use of High Risk Medications in the Elderly (DAE)

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Potentially Harmful Drug-Disease Interactions in the Elderly (DDE) • Medications should be avoided if patients have : History of Falls:  anticonvulsants, non-BZD hypnotics, SSRIs, antiemetics, antipsychotics, BZD or TCA Dementia:  antiemetics, antipsychotics, BZD, TCA, H2 Blocker, non-BZD hypnotics or anticholinergics • Exclusions Falls and Dementia • Bipolar, psychosis, schizophrenia, seizure disorder Chronic Kidney disease (ESRD, stage 4 CKD, kidney transplant):  Cox-2 selective NSAIDs or nonaspirin NSAIDs

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• WM is a 68 year-old male  Hearing loss, rt eye blindness, lft eye

cataracts, Hyperlipidemia, IBS, GERD, Pre-diabetes, Atherosclerosis of aorta, BPH  Zolpidem, paroxetine, simvastatin, ASA, famotidine  Presented to ED after a sudden fall while walking his dog alone  He lost consciousness for less than a minute. He then got up and felt a little "wobbly" but no weakness.  He denied any chest pain or SOB. No headache. No recent illness. No N/V or diarrhea.  Vitals were normal and stable. All tests wnl.

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Drug-Disease Interactions in Pts ≥ 67 years with a History of Falls Medication

Indication

Alternative Mediation

Anticonvulsants

Neuralgia or Anxiety

Duloxetine (Cymbalta®) 30mg daily (max 60mg/day) Preferred Venlafaxine (Effexor ®) 37.5 mg QHS can titrate up 225mg (divided BID to TID)

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Drug-Disease Interactions in Pts ≥ 67 years with a History of Falls Medication

Indication

Alternative Mediation

SSRIs

Anxiety Depression

Duloxetine (Cymbalta®) 30mg daily (max 60mg/day) Preferred Venlafaxine (Effexor ®) 37.5 mg QHS can titrate up 225mg (divided BID to TID)

Antiemetics Prochlorperazine (Compazine®) Promethazine (Phenergan®)

Antipsychotics

Nausea/Vomiting

Ondansetron (Zofran®) 48mg BID PRN nausea/vomiting (unless pt already on active chemotherapy regimen)

Cough

Robitussin

Insomnia

Non pharmacologic: “Sleep Hygiene” practices Trazodone (Desyrel®) 25 50mg QHS PRN sleep

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Drug-Disease Interactions in Pts ≥ 67 years with a History of Falls Medication

Indication

Alternative Mediation

Benzodiazepines

Sleep

Non pharmacologic: “Sleep Hygiene” practices Trazodone (Desyrel®) 25 -50mg QHS PRN sleep

TCAs

Peripheral/DM Neuropathy

Duloxetine (Cymbalta®) 30mg daily (max 60mg/day) Preferred. Venlafaxine (Effexor ®) 37.5 mg QHS can titrate up 225mg (divided BID to TID)

Nonbenzodiazepine Hypnotics: Eszopiclone (Lunesta®) Zaleplon (Sonata®) Zolpidem (Ambien®)

Insomnia

Non pharmacologic: “Sleep Hygiene” practices Trazodone (Desyrel®) 25-50mg QHS PRN sleep

Insomnia

Non pharmacologic: “Sleep Hygiene” practices Trazodone (Desyrel®) 25 -50mg QHS PRN sleep

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HEDIS & CMS Measure of Drug-Disease Interactions in Pts ≥ 67 years with Dementia Medication

Indication

Alternative Mediation

H2 receptor antagonists Cimetidine (Tagamet®) Famotidine (Pepcid®) Nizatidine (Axid®) Ranitidine (Zantac®)

GERD

No alternatives, PPI should also be avoided.

Antihistamines Brompheniramine (Bromax®) Carbinoxamine (Palgic®) Chlorpheniramine (Chlor-Trimeton®) Clemastine (Tavist®) Cyproheptadine (Periactin®) Dimenhydrinate (Dramamine®) Diphenhydramine (Benadryl®) Hydroxyzine (Atarax®) Loratadine (Claritin®) Meclizine (Antivert®)

Urticaria

Antimuscarinics (oral) Darifenacin (Enablex®) Fesoterodine (Toviaz®) Flavoxate (Urispas®) Oxybutynin (Ditropan®) Solifenacin (Vesicare®) Tolterodine (Detrol®) Trospium (Sanctura®)

Cetirizine (Zyrtec®) OTC 5-10mg daily Fexofenadine (Allegra®) OTC 60mg BID or 180mg daily

Allergic Rhinitis

Fluticasone (Flonase®) 1-2 sprays each nostril daily Cetirizine (Zyrtec®) OTC 5-10mg daily Fexofenadine (Allegra®) OTC 60mg BID or 180mg daily

Pruritis

Cetirizine (Zyrtec®) OTC 5-10mg daily Fexofenadine (Allegra®) OTC 60mg BID or 180mg daily

Urinary Retention

Assess continued need for medication. Oxytrol ® Patch OTC (Oxybutynin) apply twice weekly

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HEDIS & CMS Measure of Drug-Disease Interactions in Pts ≥ 67 years with Dementia Medication

Indication

Alternative Mediation

Nonbenzodiazepine hypnotics: Zolpidem (Ambien®)

Insomnia

Non-pharmacologic: “Sleep Hygiene” practices Trazodone (Desyrel®) 25-50mg QHS PRN for sleep

Antispasmodics Atropine Belladonna alkaloids (Donnatal®) Dicyclomine (Bentyl®) Homatropine (Equipin®) Hyoscyamine (Levsin®) Propantheline (Pro-Banthine®) Scopolamine (Scopoderm®)

Chronic constipation

Will not convert, hard stop – except hospice or palliative

Skeletal muscle relaxants Carisoprodol (Soma®) Cyclobenzaprine (Flexeril®) Orphenadrine (Norflex®) Tizanidine (Zanaflex®)

Muscle Tension/Rigidity

Diarrhea Abdominal pain

Assess continued need for medication. Non-Pharmacologic: Heating Pads OTC, treat contributing problems (footwear, correct seating), physiotherapy, nerve blocks Acetaminophen 325-500mg TID-QID (Max 4gm/day)

Anti-Parkinson agents Benztropine (Cogentin®) Trihexyphenidyl (Artane®)

Extrapyramidal Movements

Assess continued need for medication. No alternatives

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HEDIS High-Risk Meds in the Elderly ≥ 66yr (DAE) Class

Medication

Anticholinergics (exclude TCAs) First-generation antihisamine

Bropheniramine Carbinoxamine Chlorpheniramine Clemastine Cypoheptadine Dexbrompheniramine

Anticholinergics (exclude TCAs) Anti-parkinson agents

Benztropine (oral) Trihexyphenidyl

Antithrombotics

Dipyridamole (oral short-acting) Ticlopidine

Cardiovascular, alpha agonist, central

Guanabenz Guanfacine

Methyldopa

Cadiovascular, other

Disupuramide

Nifedipine (IR)

Skeletal muscle relaxants

Carisoprodol Chlorzoxazone Cyclobenzapine

Metaxalone Methocarbamol Orphenadrine

Pain medications

Indomethacin Ketorolac

Meperidine Pentazocine

Dexchlorpheniramine Diphenhydramine (oral) Doxylamine Hydroxyzine Promethazine Triprolidine

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HEDIS High-Risk Meds in the Elderly ≥ 66yr (DAE) Class

Medication

Tertiary TCAs (CNS)

Amitriptyline Clomipramine

Imipramine Trimipramine

Barbiturates (CNS)

Amobarbital Butabarbital Butalbital Mephobarbital

Pentobarital Phenobarbital Secobarbital

Vasodilators (CNS)

Ergot mesylates

Isoxsuprine

CNS, other

Thioridazine Chloral Hydrate

Meprobamate

Estrogens w or w/o prgestins (oral, patch)

Conjugated estrogen Esterified estrogen

Estradiol Estropipate

Sulfonylureas (long duration)

Chlopropamide

Glyburide

Endocrine, other

Desiccated thyroid

Megestrol

Gastrointestinal, other

Trimethobenzamide

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HEDIS High Risk Medications with Days Supply Criteria Class

Medications

Days Supply Criteria

Anti-Infectives

Nitrofurantoin

>90days

Non-BZD hypnotics

Eszopiclone Zaleplon Zolpidem

>90days

High Risk Medications with Average Daily Dose Criteria Class

Medications

Average Daily Dose Criteria

Alpha agonist (central)

Reserpine

>0.1 mg/day

Cardiovascular

Digoxin

>0.125mg/day

Tertiary TCAs

Doxepin

>6mg/day

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Patient WM • Reason for fall is unclear. Workup in the ED has been

unremarkable. There is no clinical signs and symptom to suggest CVA, seizure or acute coronary syndrome. • No criteria for admission. Patient was discharged with the

same medications. He went home ambulatory accompanied by wife. • However, WM’s fall may be associated with

the medications that he was taking…

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Patient WM

Medication requiring review  Zolpidem  Paroxetine  Simvastatin  Aspirin  Famtodine

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WM Safer Alternatives • WM is using Ambien 5mg for insomnia • Consider alternative: “Sleep Hygiene” practices  Trazodone (Desyrel®) 25 -50mg QHS PRN sleep

• WM is using paroxetine 10mg for IBS • Consider alternative:  physician should discuss benefit versus risk with WM and see if he can taper off the med when it is no longer necessary

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Medications that cause Hospital Admission

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Data by Age, most over 55

Hyponatremia Patient Cast SC 59 yo white female w/HTN and depression: Chorthalidone 12.5mg 2/2011 Fluoxetine 40mg daily 3/2013 Na trends: Baseline: 124-134 2011: 126-130 2012-13: None 1/2/2014: 122 1/7/14: Office visit, flu shot given and TCA for insomnia, start Na tablets 1/13/14: Pt calls, has vomiting/diarrhea. Told to take imodium. Restrict free water but now everything is changed. Pt to continue the salt tab if she can keep it down. Do not restrict fluids/ free water at this time with her gastroenteritis. But rather drink lots of Gatorade, 7-Up, Propel, etc. Any drink with electrolytes. Eat potato chips. Safety Net intervened: Stopped the chothalidone & Na tablets, and repeat lab. Physician also dc’d the TCA and changed fluoxetine to venlafaxine. Now Na is 139. 22

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SCAL Variation of self reported vs data from clarity on ADVERSE EVENTS Self Reported: TOTAL 502013 Clarity: TOTAL >3500 45 40 35 30 25 20 15 10 5 0

3000 2500 2000 1500 1000 500 0

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New Safety Net: Thiazide-type induced Hyponatremia Workflow

BPAs coming

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New Safety Net: Medication induced Hyperkalemia Workflow

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High Dose Digoxin (>0.125) ≥ 66yr old

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Medication Management

Medication Reconciliation

Medication Adherence

Medication Safety

Mission: To reduce harm and hospital/ER visits by managing medications responsibly across the continuum…ensuring benefit always outweighs the risks.

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Summary • Baby boomer are aging • Understand the physiological and PK changes in elderly • • • •

so we can adjust the medications accordingly Elderly patients are at a high risk for an medication adverse event that may end up with an admission Drug interactions, drug disease interactions, adherence and lab values are important components to consider Diet education to prevent low Na and High K It is important to review the appropriate use of the the medications that should be avoided for patients who have history of falls, dementia and CKD and know the alternatives for those medications

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Reference: • HEDIS 2014.National Committee of Quality Assurance. • Klotz U. Drug Metab Rev. 2009;41(2):67-76.JACC

2010;56(21):1683-92 • Klotz U. Drug Metab Rev. 2009;41(2):67-76.Hutchison LC. J Pharm Pract. 2007;20:4.

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Thank you!

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