Managing Polypharmacy:Thinking outside the [dosette] box

Martin Wilson

Consultant Physician

Care of the Elderly

NHS Highland

What are we going to do?

• A quick run through core principles and challenges in Polypharmacy Management

• Example from the receiving unit

Disclaimers

• Stopping drugs is not the primary goal

• Thinking openly and carefully is the goal

Three overlapping areas

Multimorbidity Frailty

Polypharmacy

Multimorbidity

Barnett K, Mercer SW, Norbury M et al. Epidemiology of multi-morbidity and implications for healthcare, research, and medical education: a cross sectional study. The Lancet

2012:380:37-43

Multimorbidity is common

Multimorbidity

Polypharmacy

ISD

Source ISD

Multimorbidity Frailty

Polypharmacy

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Functional history as important as Past Medical History

Steady Dwindiling

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Clegg et al. Frailty in elderly people. The Lancet, Vol 361, Issue 9868, 2013,752-762

So how old is your patient?

• Lots of old folk who are physiologically younger than years

– Most of whom will be rich

• Lots of younger folk who are physiologically older than years

– Many of whom be deprived

What category is your patient in?

Multimorbidity

Frail

Polypharmacy

FrailPolypharmacy

Multimorbidity PolypharmacyFrail

What category is your patient in?

Multimorbidity

Frail

Polypharmacy

Frail Polypharmacy

Multimorbidity Polypharmacy Frail

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Stroke

Diagnosed

Diabetes Vascular

Dementia

COPD

Fall and

Lumbar

vertebral

fracture

Hospital

Admission

Recurrent

UTIs

MI

Medication

• Metformin 1 g TDS

• Gliclazide 160mg bd

• Calcichew D3 forte 1 tab twice a day

• Alendronate 70mg once a week

• Perindopril 4mg once a day

• Indapamide 2.5mg once a day

• Seretide 250 1 puff twice a day

• Apixiban 5 mg twice a day

• Salbutamol as required

• Ipratropium Inhaler 4 times a day

• Clopidogrel 75mg once a day

• Atorvastatin 80mg once a day

• Mirtazapine 30mg nocte

• Zopicolone 7.5 mg at night

• Oxybutinin 5mg bd

• Thyroxine 150mcg once a day

• Ipratropium inhaler 4 times a day.

• Paracetamol 1g QDS

• Omeprazole 20mg once a day

• Trimethoprim 200mg once a day prophylaxis

Medication

• DIABETES– Metformin 1 g TDS– Gliclazide 160mg bd

• OSTEOPOROSIS– Calcichew D3 forte 1 tab twice a

day– Alendronate 70mg once a week

• POST CVA– Perindopril 4mg once a day– Indapamide 2.5mg once a day– Apixiban 5 mg twice a day

• COPD– Seretide 250 1 puff twice a day– Salbutamol as required – Atrovent inhaler 4 times a day

• POST MI– Clopidogrel 75mg once a day– Atorvastatin 80mg once a day

• MOOD /BEHAVIOUR– Mirtazapine 30mg nocte– Zopicolone 7.5 mg at night

• BLADDER– Oxybutinin 5mg bd

• ENDOCRINE– Thyroxine 150mcg once a day

• OTHER– Paracetamol 1g QDS– Omeprazole 20mg once a day– Trimethoprim 200mg once a day

prophylaxis

Emergency admission

• Crushing central chest pain at home

• Sweaty and clammy

• Resolved after morphine

• Now up and about on the ward. Confused looking for husband

Tests

• Troponin >> lots

• ECG > Deep inverted anterior T waves/ AF (old)

• Chest X ray > mild congestion (but poor film)

• BP 98/40

• Urea 10 Creat 132

– Baseline Urea 8 / Creat 124

• WBC 8.6 Hb 98 MCV 92 Plat 140

Diagnosis

• Acute Coronary Syndrome

• Delirium

Management

• Cardiology

– Medical Management would not angio

– ECHO if tolerated

• Nursing

– Up and about a lot increasingly distressed

So what is ‘medical management’ here ?

• Fondaparinux /Clopidogrel /Aspirin /Apixiban

– NO!

• Aspirin and Clopidogrel and Fondaparinux

• Clopidogrel and Apixiban

• Aspirin and Apixiban

• Aspirin and Clopidogrel

• Clopidogrel

• Aspirin

• ????

How do guidelines help us manage these groups?

Honesty about Guidelines

• Done with a SINGLE disease in mind

• Based on studies in non- frail

• Are not made with the frail or multimorbid in mind

• They are GUIDElines but– Can be VERY hard to ‘defy’ them

• Almost no trial evidence in frail adults

– Different pharmacology

– Huge comorbidity

• Use the best we have ie younger adults

– Different Absolute Risk

– Different Harm rates.

• Almost no trial evidence in frail adults

– Different pharmacology

– Huge comorbidity

• Use the best we have ie younger adults

– Different Absolute Risk

– Different Harm rates.

Why did you jump off a cliff?

Because the Guideline told me to.

Game changing concepts

If guideline says Prescribe X drug it is GUIDANCE not INSTRUCTION and not prescribing may well be acceptable (and often desirable) in a range of situations

One size does not fit all.....

Beware Extrapolation

Rivaroxaban with or without Aspiring in Stable Cardiovascular Disease Eikelboom et al NEJM

2017; 377 (14) 1319 - 1330

Comparative effectiveness of high-dose versus standard-dose influenza vaccination on

numbers of US nursing home residents admitted to hospital: a cluster-randomised trial

Gravenstein S et al., Lancet Respir Med. 2017;5(9):738-46).

– What are the patients priorities likely to be?

– What are there carers priorities likely to be?

– What are the Health Service Priorities likely to be?

Medication

• Metformin 1 g TDS

• Gliclazide 160mg bd

• Calcichew D3 forte 1 tab twice a day

• Alendronate 70mg once a week

• Perindopril 4mg once a day

• Indapamide 2.5mg once a day

• Seretide 250 1 puff twice a day

• Salbutamol as required

• Ipratropium Inhaler 4 times a day

• Clopidogrel 75mg once a day

• Atorvastatin 80mg once a day

• Mirtazapine 30mg nocte

• Zopicolone 7.5 mg at night

• Oxybutinin 5mg bd

• Thyroxine 150mcg once a day

• Ipratropium inhaler 4 times a day.

• Paracetamol 1g QDS

• Omeprazole 20mg once a day

• Trimethoprim 200mg once a day prophylaxis

Medication in the Frailest Adults

• Blood pressure - avoid blood pressure < 130 systolic and or < 65 diastolic [except in LVSD]

• Blood sugar control - avoid lowering HbA1c < 65

• Treatments to maintain renal function and avoid progression of proteinuria - avoid treating unless considered to have sufficient life expectancy to see benefit

• Use of blood thinners - avoid the use of combination blood thinners

• Heart rate control - reduce or stop heart rate limiting medication if pulse < 60

Polypharmacy Guidance, Realistic Prescribing 3rd Edition, 2018. Scottish

Government Polypharmacy Model of Care Group.

This lady

• Aspirin or Clopidogrel alone

• A lot less of her other medication….

Facts and figures• BP 106/56

• HbA1c 40 mmmol/mol 5.8%

• Urine Albumin/Creat ratio – trace microalbuminuria

• Creatinine 124 eGFR 45

• ECG Atrial Fibrillation 62 bpm

• Weight 43kg

?

?

?

?

?

?

?

• [Postural] Blood Pressure too low ?

• Blood Sugar too low?

• Blood too thin [ed]?

• Kidneys too vulnerable?

• Any Messy drugs ?

Three Take Home Messages

• Addressing Polypharmacy begins and ends with individualised patient defined goals

• Frailty is a more useful concept than chronological age

• Better knowledge of efficacy and risk can aid decision making