POLYPHARAMCY: Define polypharmacy and develop a practice model to minimize the risk of polypharmacy Michelle Compton, Pharm.D. Kaiser Permanente Kern County Service Area September 11, 2008
Now it is time to address issues related to “Polypharmacy”
Is this an example of polypharmacy ? Current Medications from KPHC: ¾ NTG 0.4 mg SL prn ¾ Lovastatin 20 mg: QD (but patient says she is on simvastatin) ¾ Atenolol 25 mg: ½ BID ¾ Furosemide 20 mg: PRN swelling of lower extremities (usually uses for 2 to 4 days every week) ¾ HCTZ 25 mg: Q AM ¾ Famotidine 40 mg: noon and HS ¾ Omeprazole 20 mg: BID ¾ Metoclopramide 5 mg: TID and HS PRN acid reflux ¾ Citalopram 40 mg: 1 QD ¾ Cozaar 25 mg: 1 QD ¾ Tylenol Extra Strength: PRN ¾ Calcium Citrate + D: 1 QD ¾ One-A-Day Womens Formula: 1 QD ¾ Cyclobenzaprine 10 mg: 1 TID PRN ¾ Nortriptyline 10 mg: 2 Q HS PRN ¾ Warfarin 4 mg: per Anticoagulation Service ¾ Diclofenac 50 mg: BID
1
Define polypharmacy and describe the offense which best describes polypharmacy ¾
Excessive and unnecessary use of drugs vs wellcontrolled and thoughtful drug regimen
¾
Offense is not the number of medications prescribed, but the illogical selection or use of pharmacologic agents
¾
Problem compounded by different providers prescribing appropriate (or inappropriate) drugs for documented or suspected medical condition(s) with no oversight of overall plan (fragmented medical care)
Describe at least 5 consequences linked to polypharmacy ¾
Increased frequency/severity of side effects
¾
Increased difficulty separating drug-induced vs disease state-induced symptoms
¾
Increased difficulty with interpretation of lab data
¾
Increased risk of drug-drug, drug-food, drug-dietary supplement, and drugdisease state interactions
¾
Increased risk of adverse drug reactions requiring medical intervention (health care provider visit, hospitalization)
¾
Reduction in patient compliance with therapeutic regimen
¾
INCREASE IN OUT OF POCKET EXPENSES (copay for medications/lab tests/ monitoring supplies; Medicare Donut Hole; office visits/ER visits/ hospitalization)
Develop a practice model, with respect to prescribing medications, which minimizes the risk of polypharmacy Before Prescribing a Prescription Medication (or recommending an OTC or Herbal Product) Ask and Answer the Following: ¾ Is the complaint/finding/problem related to: • Recent change in dose of current RX or OTC medication? • Recent addition of new RX or OTC medication? • Recent addition of alternative therapy (eg, dietary supplement? ¾ Does the complaint/finding/problem need an intervention? ¾ Can the problem be managed without pharmacologic intervention?
2
Develop a practice model, with respect to prescribing medications, which minimizes the risk of polypharmacy – cont’d If a pharmacologic intervention is required: ¾
Which agent(s) would be least likely to produce side effects or iatrogenic disease?
¾
Which agent(s) would have the lowest drug-interaction and disease state-interaction risk?
¾
Which agent(s) offer maximum benefit with the simplest dosage schedule and lowest cost?
¾
Which agent(s) require no monitoring or simple monitoring techniques?
¾
What therapeutic endpoints will document optimal outcome (ie, “What is the Destination?”)
Develop a practice model, with respect to prescribing medications, which minimizes the risk of polypharmacy – cont’d
¾
Start Low – Go Slow: Careful titration to endpoint or target
¾
Empower Patient/Family/Caregiver to Make Better Decisions
¾
Regularly Re-Evaluate Need. Have we reached the “Destination?”
Develop a practice model for a “medication reduction program” to address questionable medications. “I wonder if we really need this medication?”
Identify medical need. If no medical need identified: ¾ Establish monitoring criteria for drug effect (eg, blood pressure, blood sugar, fluid retention, mental status, behavioral change) ¾ Reduce dose by 25% and evaluate pre-established monitoring criteria ¾ If no changes in monitoring criteria at steady state (5 half-lives) reduce dose by additional 25% and continue monitoring preestablished criteria ¾ If a given dosage-reduction results in change in established monitoring criteria (which would indicate medical need), escalate dose to previous level for maintenance ¾ monitor for changes indicating medical need (eg, elevations in blood sugar, blood pressure, symptoms of previously controlled disease)
3
Is this an example of polypharmacy ? Current Medications from KPHC: ¾ NTG 0.4 mg SL prn ¾ Lovastatin 20 mg: QD (but patient says she is on simvastatin) ¾ Atenolol 25 mg: ½ BID ¾ Furosemide 20 mg: PRN swelling of lower extremities (usually uses for 2 to 4 days every week) ¾ HCTZ 25 mg: Q AM ¾ Famotidine 40 mg: noon and HS ¾ Omeprazole 20 mg: BID ¾ Metoclopramide 5 mg: TID and HS PRN acid reflux ¾ Citalopram 40 mg: 1 QD ¾ Cozaar 25 mg: 1 QD ¾ Tylenol Extra Strength: PRN ¾ Calcium Citrate + D: 1 QD ¾ One-A-Day Womens Formula: 1 QD ¾ Cyclobenzaprine 10 mg: 1 TID PRN ¾ Nortriptyline 10 mg: 2 Q HS PRN ¾ Warfarin 4 mg: per Anticoagulation Service ¾ Diclofenac 50 mg: BID
MEDICATION THERAPY MANAGEMENT (MTM) Protocol Management (approved by PCP)
68 y.o. woman enrolled in MTM program DKA first appointment 4/4/08 Called to r/s: queried re: any urgent problems with meds that would indicate need for ASAP appointment. Only concerns: tired all the time; started on citalopram for depression last year but seems to have lost effectiveness after a couple of months; straight Medicare Part D – likely to “fall” into Donut Hole again this year
Interesting Case – cont’d Problem List: ¾ GERD ¾ Barrett’s Esophagus ¾ Osteoarthritis ¾ Hyperlipidemia ¾ Hypercoagulable State ¾ Polymyalgia Rheumatica ¾ Hypertension ¾ Depression ¾ Spinal Stenosis ¾ Postlaminectomy Syndrome – Lumbar region ¾ Mixed incontinence
4
Interesting Case – cont’d Depression: citalopram failure vs worsening condition vs medication side effect: Any of the following reported to cause depression? ¾ NTG 0.4 mg SL prn ¾ Lovastatin 20 mg: QD ¾ Atenolol 25 mg: ½ BID ¾ Furosemide 20 mg: PRN swelling of lower extremities ¾ HCTZ 25 mg: Q AM ¾ Famotidine 40 mg: noon and HS ¾ Omeprazole 20 mg: BID ¾ Metoclopramide 5 mg: TID and HS prn acid reflux ¾ Citalopram 40 mg: 1 QD ¾ Cozaar 25 mg: 1 QD ¾ Tylenol Extra Strength: PRN ¾ Calcium Citrate + D: 1 QD ¾ One-A-Day Womens Formula: 1 QD ¾ Cyclobenzaprine 10 mg: 1 TID PRN ¾ Nortriptyline 10 mg: 2 Q HS PRN ¾ Warfarin 4 mg: per Anticoagulation Service ¾ Diclofenac 50 mg: BID
Interesting Case – cont’d Citalopram – Metoclopramide timeline: Jan 4, 2007: Citalopram 40 mg QD April 24, 2007: Metoclopramide (added to famotidine + omeprazole secondary to continuing GERD symptoms at least once a day- described as severe). Since starting metoclopramide reflux symptoms decreased to 3 to 4 times/week but still described as severe. Plan: Temporarily DC metoclopramide – if reflux symptoms worsen, will restart
Interesting Case – cont’d F/U: April 7, 2008 ¾ Off metoclopramide ¾ No change in GERD symptoms ¾ Dramatic improvement in sleepiness (tiredness) and increase in interest ¾ Assessment: 1. Possible metoclopramide-induced depression 2. Suboptimal control of GERD 3. Needs full MTM medication review
5
Interesting Case – cont’d April 9. 2008: Full MTM medication review via telephone (per patient request). Findings: 1. Risk of “falling” into Donut Hole 2. Depression: since stopping metoclopramide has noted: waking up feeling refreshed: no longer sleeping all day long; increased energy and interest (“going to church – first time since last spring”) 3. Hyperlipidemia: taking 80 mg simvastatin QD (obtains from Costco – RX changed last year while in Donut Hole and was less expensive at Costco and has continued to get refills) 4. Hypertension: BP at goal. HX ACE-I cough 5. GERD/Barret’s Esophagus: taking famotidine and omeprazole BID (with breakfast and just before bed) 6. Edema: takes HCTZ and furosemide together PRN edema. Not based on weight changes. Usually uses for 3 to 4 consecutive days Q week. 7. Osteoporosis prevention: approx 300 mg elemental calcium/day via diet. Calcium Citrate + D (250 mg elemental Calcium/tablet) BID. 8. SL NTG – does not know how to use nor how to refill (expires 6/08)
Interesting Case – cont’d Assessment/Plan: 1) Donut Hole risk: move following generic meds to Walmart ($4/30 day supply and no impact on her Medicare Fund): famotidine, HCTZ, citalopram, atenolol, nortriptyline, furosemide, diclofenac, warfarin and cyclobenzaprine; move simvastatin to KP for $22/3 months via mail order (will reduce OOP expenses – copays) by approximately $1000/year. 2) Metoclopramide-induced depression. 3) Hyperlipidemia: need lipid panel/liver enzymes to evaluate simvastatin effect 4) GERD/Barretts Esophagus: suboptimal control secondary to improper use of omeprazole (with breakfast and HS with no post-HS food intake). Change omeprazole to 2 capsules first thing Q AM (move to bathroom). 5) Osteoporosis prevention: suboptimal calcium intake (approx 800 mg/day with target of 1500 mg/day. Change to 500 mg calcium carbonate + D/tablet and take TID with meals. 6) Edema: taking HCTZ and furosemide together does not enhance diuretic effect. Will take HCTZ at least 30 min. before furosemide on days she has edema. Will develop “sliding diuretic plan based on daily weights” once we determine baseline weight. 7) Does not understand NTG use or replacement. Educate re: appropriate use and refill intervals.
Interesting Case – cont’d Telephone f/u 4/17/08 ¾ Picked up generic medications from Walmart ¾ No GERD symptoms since changing omeprazole to 2 Q AM (first thing in the AM) ¾ Taking furosemide 30 to 60 minutes after HCTZ – edema resolves with one day of therapy instead of 3 to 4 ¾ No symptoms of depression
6
Interesting Case #2 63
y/o male Problem List: – Type 2 Diabetes – Hypertension – Hyperlipidemia – Osteoarthritis
Interesting Case #2 - cont Medication
List:
– Labetolol 200mg BID for BP control – Novolin NPH insulin – Novolog insulin – Simvastatin 10mg QD – HCTZ 25mg QD
Interesting Case #2 - cont
Patient presents to ER with chest pain, arm numbness DOES NOT PROVIDE A LIST OF HIS CURRENT MEDICATIONS DX: AMI, PTCA with stent placement Discharge medications: – – – – –
Lisinopril 10mg QD Atenolol 25mg QD ASA EC 325mg QD Plavix 75mg QD Minitran patch 0.2mg/hr ON in AM, OFF in PM
7
Interesting Case #2 - cont At
FU with PCP, patient c/o dizziness when he stands up or moves around, new complaint since hospital discharge, BP 143/76, HR 68 PCP reluctant to change any meds started by cardiologist Advised to discuss with cardiologists at scheduled appt in 2 weeks
Interesting Case #2 - cont IS
THIS AN EXAMPLE OF POLYPHARMACY? Duplicate beta blocker use is polypharmacy and maybe contributing to symptoms Stopped Atenolol (Labetolol has beta/alpha blockade) 2 weeks later no complaints of dizziness, feels better, BP 130/38 HR 84
Ambulatory Care Pharmacy Services: Your “secret weapon” to help manage patients with medicationrelated problems Understand the value of an ambulatory care pharmacist as a professional colleague in evaluating and resolving perceived polypharmacy issues in your patients
8
OBJECTIVES: At the end of this presentation the participants should be able to:
1. 2. 3. 4.
5.
Define polypharmacy and describe the offense which best describes polypharmacy. Describe at least 5 consequences (to both providers and patients) linked to polypharmacy. Develop a practice model, with respect to prescribing medications, which minimizes the risk of polypharmacy Develop a practice model for a “medication reduction program” to address questionable medications (“I wonder if we really need this medication?) Understand the value of an ambulatory care pharmacist as a professional colleague in evaluating and resolving perceived polypharmacy issues in your patients
9