Identifying and Deprescribing Potentially Inappropriate Medications Kacey Carroll

Identifying and Deprescribing Potentially Inappropriate Medications Kacey Carroll, Pharm. D, BCGP, BCACP March 15, 2019

Biography Kacey Carroll, Pharm. D, BCGP, BCACP, is a graduate of Butler University. She is an assistant professor of pharmacy practice at Butler University specializing in ambulatory care and geriatrics. She works in a clinical practice setting at St. Vincent’s Primary Care Center and the Center for Healthy Aging. She also assists in training pharmacy and medical residents. 2

Financial Disclosure This speaker has no conflict of interest to disclose 3

Medication Use in the Elderly • Approximately 30% of adults age 65 and older take 5 or more medications • Older patients purchase 33% of all prescription drugs • Expected to increase to 50% by the year 2040 • Inappropriate polypharmacy cost 1. 3 billion dollars in avoidable health care costs in 2012 Prescribing cascade: Drug 1 Adverse effect interpreted as a new condition Drug 2 Nurs Clin N Am 2017; 52: 457– 468.

Pharmacodynamic and Pharmacokinetic Changes Body Composition 5 Drug Absorption Elimination Pharmacodynamic Changes Decreased body mass (primarily muscle) Decrease in gastric acid production Decrease renal blood flow Reduced sensitivity to ß-adrenergic stimulation Increase in total body fat Slowed gastric emptying and GI transit Decrease GFR Impaired baroreceptor reflex Decrease in total body water Skin changes- thinning of the skin and decreased fatty tissue More sensitive to antagonism of cholinergic receptors Eur J Clin Pharmacol 2013; 69: 319– 326 Am J Geriatr. P harmacother 2007; 5: 263 -303

Medication Appropriateness Tools for the Elderly Beers Criteria STOPP (Screening Tool of Older Persons' Prescriptions) START (Screening Tool to Alert Doctors to Right Treatment) 6

Proposed Changes to 2018 Beers Criteria • H 2 -receptor antagonists removed from the “avoid” list in patients with dementia or cognitive impairment • Glimepiride added to the list of sulfonylureas with a greater risk of severe prolonged hypoglycemia • Serotonin-norepinephrine reuptake inhibitors (SNRIs) added to the list of drugs to avoid in patients with a history of falls or fracture • Age threshold beyond which extra caution is advised for using aspirin for primary prevention of cardiovascular disease lowered to ≥ 70 years from ≥ 80 years 7 Not cited at this time as changes are pending

Medication Assessment Tools for the Elderly • Assessing medication administration and burden • • • Medication Management Instrument for Deficiencies in the Elderly (Med. Ma. IDE) Family Caregiver Medication Administration Hassles Scale (FCMAHS) Medication Regimen Complexity Index (MRCI). Medication Appropriateness Index (MAI) 1. Is there an indication for the drug? 2. Is the medication effective for the condition? 3. Is the dosage correct? 4. Are the directions correct? 5. Are the directions practical? 6. Are there clinically significant drug-drug interactions? 7. Are there clinically significant drugdisease/condition interactions? 8. Is there unnecessary duplication with other drug(s)? 9. Is the duration of therapy acceptable? 10. Is this drug the least expensive alternative compared to others of equal utility? 8 J Clin Epidemiol 1992; 45: 1045 -51

Deprescribing in the Elderly Deprescribing • • • A positive approach Patient-centered, shared decision-making, requiring informed patient consent Close monitoring of effects Potentially Inappropriate Medications 9 Deescalating therapy J Clin Outcomes Manag 2016; 23: 359 -69.

Tools to Aid in Deprescribing 10 J Clin Outcomes Manag 2016; 23: 359 -69.

Resources for Deprescribing. org Algorithms for: • • • Proton Pump Inhibitors Benzodiazepines Cholinesterase Inhibitors (Ch. EIs) and Memantine Antipsychotic Antihyperglycemic 11 https: //deprescribing. org/resources/deprescribing-guidelines-algorithms/

Questions? 12

Bibliography 13 • Kim J, Parish AL. Polypharmacy and Medication Management in Older Adults. Nurs Clin N Am 2017; 52: 457– 468 • Hubbard RE, O’Mahony MS, Woodhouse KW. Medication prescribing in frail older people. Eur J Clin Pharmacol 2013; 69: 319– 326. • Bowie MW, Slattum PW. Pharmacodynamics in older adults: a review. Am J Geriatr Pharmacother 2007; 5: 263 -303 • Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992; 45: 1045 -51 • Scott IA, Anderson K, Freeman C. Evidence-based deprescribing: reversing the tide of potentially inappropriate polypharmacy. J Clin Outcomes Manag 2016; 23: 359 -69. • https: //deprescribing. org/resources/deprescribing-guidelinesalgorithms/