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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