Download Slide 1

Perilous in
Partnering
Polypharmacy
Medication
Safety
Kevin L. Wallace, MD, FACMT
Assoc. Professor, Dept. of Pharmacy Practice
UNE College of Pharmacy
April 29, 2011
Presentation Objectives



Increase awareness of polypharmacy-related
risk factors and impact on patient outcome.
Promote use of safe and cost-effective
medication therapy management tools and
strategies.
Support interprofessional collaboration and
active patient involvement in care
management.
Case



20 yo college student admitted for chief
complaint of several week-duration morning
stiffness, unsteady gait, and dysphoria.
PMH: bipolar disorder; gastroesophageal
reflux disorder (GERD)
Medications:
 Geodon 60 mg BID
 Wellbutrin SR 150 mg QAM
 Risperdal 2 mg QHS
 E-mycin 333 mg TID
Case (cont’d)


Failed GERD treatment with Reglan due to
“muscle stiffness”
 innate susceptibility to D2 antagonistinduced dystonia/movement disorder?
Started on promotility GERD therapy (oral
erythromycin) about 2 months prior to this
admission.
 ADE determinant?
Adverse Drug Events (ADE)


ADE = medicationrelated injury
Highly vulnerable
groups include:



Elderly (>65 yrs)
Younger
adults/adolescents with
psychobehavioral
disorders
Infants/toddlers
“Collateral Damage”
ADE Incidence &
Impact

U.S. Population




Approx. 500,000 Medicare patient
ADEs/yr in outpatient setting
5th leading cause of death
Estimated cost: ~ $300
billion/yr
Patient

 quality of living

 cost of care
Gurwitz et al 2003; NEHI 2009
Major Risk Factor: Drug Provision
http://www.medscape.com/viewarticle/724186_print
ADE Risk Determinants

Drug-related





Mechanism(s) of action
and potency
Dose
Formulation
Route of administration
Frequency and duration
of use

Patient-related





Age
Genetic makeup
Psychosocial factors
Other underlying medical
disorders
Exposure to other substances
(e.g., interacting
nonpharmaceuticals)
Number of drugs in treatment regimen
= most potent ADE risk factor!
Polypharmacy – Definition?


>4 drugs per regimen
May/may not include
nonprescription (aka,
“OTC”: over-the-counter)
medications and other
supplements
Common OTC ADEs
acetaminophen
(APAP)
Elderly Polypharmacy

Seniors (13% total population)
consume:



40% of all prescription drugs
35% of all OTC drugs
Average # Rx meds/yr (OTC
NOT included)


65-69 yrs: >13
80-84 yrs: ~18
Am. Soc. Consultant Pharmacists 2004
Common Elderly
Neurobehavioral Symptoms
Balance/gait
problems
 Dizziness
 Confusion

Insomnia
 Fatigue
 Irritability
 Depressed mood

Medications & Fall Risk
Wolcott et al 2009
Prescribing Cascade
Drug treatment of other
drug-related side
effects increases ADE
risk!
(particularly when # meds
exceeds 10)
Major ADE Determinants to
Address in Patient Care

Inappropriate prescribing* (IP)

Drug regimen nonadherence*

Unexpected interactions (drugdrug, drug-disease, drug-diet, etc.)
*Overuse
and/or underuse!
IP Occurrence by Type
(1989/90) →
(1992/93) →
Treatment indication?
Hanlon et al (2002)
Other ADE Factors to Consider



Critical transition point
(e.g., hospital-to-home)
provider and/or patient
errors
Multiple prescribers per
patient
Patient-related:
 ↓ functional status
 ↓ care support (family,
finance)
Case



20 yo college student admitted for morning
stiffness, unsteady walk, and dysphoria.
PMH: bipolar disorder; gastroesophageal
reflux disorder (GERD)
Medications:
 Geodon 60 mg BID
 Wellbutrin SR 150 mg qAM
 Risperdal 2 mg qHS
 E-mycin 333 mg TID
Case (cont’d)

Failed GERD Rx with Reglan due to
“muscle stiffness” (parkinsonism?)


Relatively high susceptibility to druginduced parkinsonism?
Started on GERD therapy (oral
erythromycin) about 2 months prior to
hospitalization.
Pharmacodynamic
Determinants?
Agonist (+) or
Antagonist (- )
Drug

Wellbutrin
(bupropion)
D2
+
Geodon
(ziprasidone)
-
-
Risperdal
(risperidone)
-
-
Direct Adverse Drug Effects?
Drug
Extrapyramidal Side Effects
(EPS)*
Wellbutrin
No
Geodon
Maybe
Risperdal
Maybe
Erythromycin
No
*EPS:
dystonia, parkisonism
Pharmacokinetic (PK) Factors?
Phase I Metabolism - CYP450:
Drug
2D6
bupropion
↓
erythromycin
3A4
↓
PK Interactions of Concern
Geodon (ziprasidone) Level
Drug
2D6
3A4
bupropion
erythromycin

PK Interactions of Concern
Risperdal (risperidone) Level
Drug
2D6
Wellbutrin

Erythromycin
3A4

Clinical Effects of Concern
Drug
EPS
Wellbutrin
Indirect
Geodon
Direct
Risperdal
Direct
Erythromycin
Indirect*
*Straw
that broke the camel’s back?
Other Effects of Concern?
Agonist (+) or
Antagonist (- )
Drug

Wellbutrin
(bupropion)
D2
+
Geodon
(ziprasidone)
-
-
Risperdal
(risperidone)
-
-
Orthostatic hypotension
ADE Primary Prevention



Reduce IP (overuse AND underuse)
Increase patient adherence
Improve practice safety and clinical
outcome
Collaborative interdisciplinary
approach!!!
F.A.M.E.* Trial (2004-06)


>65yo army hospital pts on
> 4 chronic disorder meds.
Intervention “combo”:




Pharmacist review and counseling
Regular follow-up
Use of BP- and lipid-lowering
medication blister packs
Prospective trial: consecutive
~6-mo. phases:


*
“Observation” (n = 200)
“Randomization” (n = 159)
Federal Study of Adherence to Medications in the Elderly
Brookes 2007 (Lee et al 2006)
Medication Therapy Management (MTM)
EMR
EMR =
electronic
medical
records
Pr
Patient
Pr = prescriber
Ph = pharmacist
Ph
EPR
EPR =
electronic
pharmacy
records
Error Prevention
Medication Therapy Management (MTM)
EMR
EMR =
electronic
medical
records
Pr
Patient
Pr = prescriber
Ph = pharmacist
Ph
EPR
EPR =
electronic
pharmacy
records
Medication Therapy Management (MTM)
EMR
EMR =
electronic
medical
records
Pr
Patient
Pr = prescriber
Ph = pharmacist
Ph
EPR
EPR =
electronic
pharmacy
records
Medication Therapy Review
“The single most effective and
necessary step to ensure appropriate
prescribing is to assess all medications
prescribed at every visit.”
Ballentine 2008
Missing in current practice?
SAFE Practice

Search for ADE:



Symptoms/signs
Risk factors (e.g., IP, nonadherence)
Address/Avoid:


IP (e.g., inappropriate drug, dose, frequency,
duration)
Automatic refills
SAFE Practice

Find and apply cost-effective
treatment:




Simpler/lower-cost regimen
Close monitoring (adherence, outcome)
Synchronized refills
Educate/inform:


Patient/family
Providers
Safe Practice “Rule of Thumb”
“Start low, go slow, listen and
watch closely!”
Patient’s Role
More active care partner?
In Closing…
“As lay people and physicians increase their
demands for coherent, evidence-based,
unbiased drug information, we would all be
well served by a comprehensive program to
replace our current patchwork of bad
communication and excessive promotion
with a responsible national system of
balanced, evidence-based, and user-friendly
drug information.”
Avorn & Shrank 2009

Questions?

Comments?
References






American Society of Consultant Pharmacists. Seniors at risk: designing the
system… Available at: http://www.ascp.com/publications/
seniorsatrisk/upload/AtRisk.pdf (accessed 06/21/09)
Avorn J, Shrank WH. Communication drug benefits and risks effectively:
there must be a better way. Ann Int Med 2009;150(8):563-5.
Ballentine NH. Polypharmacy in the elderly: maximizing benefit, minimizing
harm. Crit Care Nurs Q 2008;31(1):40-5.
Brookes L. Methods to improve adherence: The FAME Trial. 2007.
Available at: http://cme.medscape.com/viewarticle/552105 (accessed
06/21/09)
Gurwitz JH, Field TS, Harrold LR, Rothschild J, et al. Incidence and
Preventability of adverse drug events among older persons in the
ambulatory setting. JAMA 2003;289:1107-1116.
Hanlon JT, Schmader KE, Koronnkowski MJ, Boult C, Artz MB, et al. Use of
inappropriate prescription drugs by older people. J Am Geriatr Soc
2002;50:26-34.
References


Lee JK, Grace KA, Taylor AJ. Effect of pharmacy care program on medication
adherence and persistence, blood pressure and low-density lipoprotein
cholesterol: a randomized controlled trial. JAMA 2006;296(21)2563-2571.
Wolcott JC, Richardson KJ, Wiens MO, Patel B. Meta-analysis of the impact of 9
medication classes on falls in elderly persons. Arch Intern Med
2009;169(21):1952-60.