polypharmacy and the elderly: drugs to avoid and use with ... · polypharmacy and the elderly:...

Polypharmacy and the Elderly:Drugs to Avoid and Use with Caution

in Heart Failure

Robert L Page II, Pharm.D., MSPH, FHFSA, FCCP, FAHA, BCPS, BCGP

Professor of Clinical Pharmacy

Clinical Specialist, Division of Cardiology

Section of Advanced Heart Failure/Transplant

University of Colorado Schools of Pharmacy and Medicine

Presenter Disclosure

Financial Disclosure: There are no financial or other relationships to disclose related to this presentation

Unlabeled/Unapproved Uses Disclosure: None

Objectives• Given an older adult with heart failure, delineate specific tools to

evaluate drug complexity in order to minimize polypharmacy.

• Given an older adult with heart failure, evaluate the patient’s medication regimen and identify which medications could cause or exacerbate heart failure symptoms.

• Discuss best practices to avoid polypharmacy in the older adult with heart failure.

• Provide patient education regarding OTC and herbal supplements to avoid in the patients has heart failure.

Polypharmacy: Definition

“As older patients move through time, often from physician

to physician, they are at increasing risk of acclamation layer

upon layer of drug therapy, as a reef accumulates layer upon

layer of coral”….

Jerry Avorn, MD, 2004

Professor

Harvard Schools of Medicine and Public Health

Chief, Division of Pharmacoepidemiology

Brigham and Women's Hospital

Comorbidity ConundrumA

GIN

G

Curr Cardiol Rep. 2012;14(3):276-84.

Polypharmacy: Comorbidities

http://agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/Health_Status.pdf

10 average meds

7 average meds

11 average meds6 average meds

Health Resource Utilization

Circulation 2008;118:S_1030.

Polypharmacy: Other Reasons

Age & Ageing 2008; 37(2):138-41.

The Impact on Medications

0%

10%

20%

30%

40%

50%

60%

70%

1988-1994 1999-2002 2003-2008

0-1 2 3 4 5+

1

2

3

4

5

6

7Number of Comorbidities

0

Me

an N

um

be

r of P

rescrip

tion

Me

dicatio

ns

Pe

rce

nt

of

Pat

ien

ts w

ith

Co

mo

rbid

itie

s

Time Periods

Mean Number of Rx Medications

Circulation 2016 20;134(12):e261.

Circulation. 2016;134:32-69

MAGNITUDE DEFINITION

Major

Effects that are life-threatening or effects that lead to

hospitalization or emergency room visit.

Moderate

Effects that can lead to an additional clinic visit, change in

NYHA functional class, change in cardiac function, or

worsening cardiovascular disease (eg, hypertension,

dyslipidemia, and metabolic syndrome) or effects that lead to

symptoms that warrant a permanent change in the long-term

medication regimen.

Minor

Effects that lead to a transient increase in patient

assessment/surveillance or effects that lead to symptoms

that warrant a transient medication change.

LEVEL of EVIDENCE DEFINITION

Level A

Multiple populations evaluated. Data derived from

multiple randomized, controlled trials or meta-analyses.

Level B

Limited populations evaluated. Data derived from a

single randomized, controlled trial or nonrandomized

studies.

Level C

Very limited populations evaluated. Data have been

reported in case reports, case studies, expert opinion,

and consensus opinion.

ONSET DEFINITION

Immediate Effect is demonstrated within 1 week of drug

administration.

Intermediate Effect is demonstrated within weeks to months of drug

administration.

Delayed Effect is demonstrated within ≥1 y of drug administration.

NSAIDS

Circulation 2016 20;134(12):e261.

NSAIDS: Mechansim

Eur Heart J 2016; 37 (13): 1015-1023.

NSAIDS: Incident Heart Failure

Clin Cardiol 2016; 39 (2): 111-118

NSAIDS: The Coxibs

Lancet 2013;382:769–79.

Diabetes Management

Diabetes Care. 2017; 40(suppl 1): S1-S130.

GLP-1 Receptor Agonists

Diabetes Care. 2017; 40(suppl 1): S1-S130.

Exenatide

Liraglutide

Lixisenatide

Dulaglutide

Albiglutide

DDP4-Inhibitors

Diabetes Care. 2017; 40(suppl 1): S1-S130.

Sitagliptin

Vildagliptin

Saxagliptin

Alogliptin

SGLT2-inhibitors

Diabetes Care 2017; 40(suppl 1): S1-S130.

Dapagliflozin

Epaglifozin

Canagliflozin

Diabetes Medications

Eur J Heart Fail 2016; 19: 43-53.

In patients with type 2 DM,

with stable HF, metformin may

be used if eGFR> 30ml/min

but avoided in unstable or

hospitalized patients with HFIn patients with symptomatic

heart failure, TZDs should

NOT be used

Dipeptidyl-Peptidase 4 Inhibtiors

Dipeptidyl-Peptidase 4 Inhibitors

Diabetes Care 2016 39(Supple 2): S210-S218.

TECOS-HF

JAMA Cardiol 2016; 1(2): 126-135.

Other Drugs to Consider

Alternative Medicines

Circulation 2016;134:32-69.

Alternative Medicines

Circulation 2016;134:32-69.

Medications with High Sodium

Circulation 2016;134:32-69.

Drug Evaluation Tools

Explicit

The Beers’ Criteria

IPET

STOPP

Implicit

MAI

IPET: Improved Prescribing in the Elderly Tool

STOPP: Screening Tool of Older Persons

MAI: Medication Appropriateness Index

Lancet 2007; 370(9582): 173-84

Beers Criteria 2015

J Am Geriatric Soc 2015; 63(11): 2227-2246.

Evaluates 10 validated measures:

1. Indication

2. Effectiveness

3. Dose

4. Correct Direction

5. Practical Directions

6. Drug-drug interactions

7. Drug-disease interactions

8. Duplication

9. Duration

10. CostJ Clin Epidemiol 1992; 45(10): 1045-1051.

The Alternative---MAI

WHY…….

http://www.sciencehumor.org/wp-content/uploads/2008/06/sign_brain.jpg

Rules of ThumbConduct comprehensive medication reconciliation at each clinical visit

and with each admission. Patients should be specifically asked about

drug, dose, and frequency of all their medications, including OTC

medications and CAMs. (Class IIa; Level of Evidence C)

Evaluating the potential risks and benefits of each medication should

be considered before initiation. Medications should be categorized as

either essential to desired outcomes or optional, with an attempt made

to reduce or eliminate optional medications. (Class I; Level of

Evidence C)

It is reasonable to consider avoiding prescribing new medications to treat

side effects of other medications. The use of as-needed medications

should be limited to only those that are absolutely necessary. (Class IIa;

Level of Evidence C).

Circulation 2016;134:32-69.

Final Thoughts to Consider