Polypharmacy Dr Joanna Preston Consultant Geriatrician St Georges

Polypharmacy Dr Joanna Preston Consultant Geriatrician St. Georges Hospital

References Many of the references for this talk can be found at the MDTea website: www. thehearingaidpodcasts. org. uk

Structure I will use falls and bone health as a theme throughout the talk. Not aiming to teach you all of medicine / pharmacology! > The ‘problem’ of polypharmacy < > Appropriate Polypharmacy < > Altered drug metabolism in older adults < >Frailty in decision making < > Useful resources < > Tips <

A CASE Frank: 86 retired Attending ED with falls regularly CABG 1997 Moderate Cognitive Impairment from vascular dementia Assistance of 1 to transfer Lives alone, carers tds BP 116/80 Hb 96 Medications Aspirin 75 mg Clopidogrel 75 mg Nicorandil 20 mg bd ISMN M/R 120 mg Betahistine Atorvastatin 80 mg Ferrous Fumerate 210 mg tds Senna 2 nocte Movicol 1 sachet bd Lansoprazole 30 mg

LAST DECADE Average number of medications person increased by IS POLYPHARMACY A PROBLEM? NH RESIDENTS On medications that are unnecessary 54% ADMISSION 5. 6% 1/4 40% 3 x For those on >10 medications >10 DRUGS From 1. 9% 10 years ago OVER 65 s On medications that are unnecessary 6. 5% ADRs Admissions due to Adverse Drug Reactions

WHAT IS POLYPHARMACY? PREVIOUSLY REGULARLY 4 -5 >15 MULTIMORBIDITY 10 -14 <10 VULNERABLE

NG 56: MULTIMORBIDITY Use an approach to care that takes account of multimorbidity for adults of any age who are prescribed 15 or more regular medicines, because they are likely to be at higher risk of adverse events and drug interactions. Consider an approach to care that takes account of multimorbidity for adults of any age who: - are prescribed 10 to 14 regular medicines are prescribed fewer than 10 regular medicines but are at particular risk of adverse events. ’

APPROPRIATE POLYPHARMACY? Numbers are less useful at guiding what is appropriate or inappropriate polypharmacy. An example of appropriate polypharmacy may be a robust older person who has had a heart attack and now has heart failure, it may be appropriate for them to be on 7 or 8 different medications. Just as important to ensure people are on appropriate medications as to remove those that are not.

What do I say? > The drugs might not have changed, but you and your body have. > We are in an evidence light zone. The original studies for many of these drugs were for one condition, in younger people. It was probably right for you at the time when this started but things have changed. > Many of the medications you are on, work over many years, so you’ll still see the benefit from having taken them going forwards, but those you take now you will see the benefit over the next few years. > It’s time to focus your medication on the things that will help you here and now / over the next few years. > What is most important to you right now and over the next few years?

01 THE AGEING BODY “The drug might not have changed, but your body has”

Drug-drug interactions Little or no evidence of how drugs interact with each other Drugs with opposing actions E. g. diuretics and fludrocortisone

Drug-disease interactions Medications which make other conditions worse NSAIDs + AKI / Hypertension Anti-cholinergics + cognitive impairment Diuretics and renal impairment

DRUG ISSUES IN OLD AGE ABSORPTION DISTRIBUTION METABOLISM ELIMINATION

ABSORPTION Increased Gastric p. H - PPIs - Atrophic gastritis. Decrease in gastric emptying.

DISTRIBUTION Increase in body fat and decrease in body water (as a proportion of total body weight). > Volume of distribution of fat soluble drugs increases so medications such as benzodiazepines accumulate due to increased elimination half life, so can still have an effect a long time after the medication has been stopped. > Volume of distribution of water soluble drugs is decreased so water soluble drugs e. g. such as digoxin need a reduced loading dose. > Altered permeability of the blood brain barrier so the brain of an older adult can be exposed to higher levels of medication causing cognitive adverse effects

METABOLISM > Reduced hepatic blood flow can reduce clearance of medications that have high hepatic excretion ratio e. g. Amitryptiline. > Increasing number of medications -> more likely that they are taking an inducer or inhibitor of Cytochrome P 450 increasing the chance of drug-drug interactions.

ELIMINATION > Reduction in renal mass and renal blood flow with age. > e. GFR decreases by 0. 5% a year after age 20. > Affects clearance of water soluble drugs such as diuretics, digoxin and NSAIDs. > Calculate Cr. Cl for those with low weight / advanced age

Frailty increasingly recognised as being associated with poorer outcomes. Advanced frailty linked to increased mortality and morbidity. Use as a trigger for medication review and ACP.

Frailty & Diabetes NICE recommends loosening Hb. A 1 c target for those who are older or frail or for adults with type 2 diabetes: > who are unlikely to achieve longer-term risk reduction benefits e. g. reduced life expectancy > for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job > for whom intensive management would not be appropriate, for example, people with significant comorbidities. Paper in 2014 suggests those over 75 or with frailty may experience more harms from tight control than benefit (type 2): target Hb. A 1 c > 7%

02 LONG TERM BENEFITS You’ll still see the benefit of those medications you’ve been taking all those years for a while yet

MEDICINES REDUCING RISK Most drugs work over a period of time to reduce risk in the longer term e. g. good BP control over several years leads to IHD / stroke risk reduction, not day to day BP readings E. g. bisphonates take 1 -2 years to enter the bones enough to reduce the risk of fracture.

OLDER ADULTS & TRIALS > Underrepresented > When they are included often they are ‘healthy’ older people > Frailty, multimorbidity, cognitive impairment, care home residents often an exclusion criteria I. e. The evidence base is not based on where they are now.

03 PROGNOSIS It’s time to focus your medication on the things that will help you here and now / over the next few years. Focus on goals.

LIMITED LIFE EXPECTANCY Bisphonate course is 3 -5 years. They take 1 -2 years to strengthen the bones enough to reduce fracture risk. If prognosis does not exceed this, there is little utility in taking the medication.

A COMMON SCENARIO Doreen is 96 and comes to falls clinic - Symptomatic postural drop: 116/78 to 96/70 - Ischaemic Heart Disease, AF. - Ramipril 5 mg, amlodipine 10 mg, rivaroxiban - Pristine compliance for 20 years, was told she’d be on these medications forever. Not keen to change anything.

LINK TO GOALS Ask what goal is: BP control or staying upright? Broader goals: day to day symptoms or longer term reduction of risk?

A COMMON SCENARIO Doreen is 96 and comes to falls clinic - Symptomatic postural drop: 116/78 to 96/70 - Ischaemic Heart Disease, AF. - Ramipril 5 mg, amlodipine 10 mg, rivaroxiban - Pristine compliance for 20 years, was told she’d be on these medications forever. Not keen to change anything.

04 TIPS Triggers fro drug chart review Cascades Anticholinergic Burden

TRIGGERS TO REVIEW A DRUG CHART Past or current toxicity - Use of high-risk drugs Age >65 years Cognitive impairment/dementia Multiple comorbidities Multiple prescribers Past or current nonadherence Renal impairment Substance abuse End of Life

PRESCRIPTION CASCADES Amlodipine Aspirin Furosemide Iron Lansoprazole Ramipril Bisoprolol Senna

USE PROBLEM LISTS Diagnosis Investigations Medication Hypertension BP 118/72 Amlodipine Aspirin as primary prevention Peripheral Oedema Echo: normal. BNP normal. Furosemide Anaemia Hb 98 No OGD Iron Lansoprazole Presumed IHD ECG normal Ramipril, Bisoprolol Constipation none Senna

WHICH MED TO USE? Diagnosis Investigations Medication Hypertension BP 118/72 Amlodipine Aspirin as primary prevention Peripheral Oedema Echo: normal. BNP normal. Furosemide Anaemia Hb 98 No OGD Iron Lansoprazole Presumed IHD ECG normal Ramipril, Bisoprolol Constipation none Senna

WHICH TO STOP Diagnosis Investigations Medication Hypertension BP 118/72 Amlodipine Aspirin as primary prevention Peripheral Oedema Echo: normal. BNP normal. Furosemide Anaemia Hb 98 No OGD Iron Lansoprazole Presumed IHD ECG normal Ramipril, Bisoprolol Constipation none Senna

ANTICHOLINERGIC BURDEN Each drug scoring 2 -3 increases risk of cognitive impairment by 50%

02 APPROPRIATE PRESCRIBING DOACs Bone Health

ANTICOAGULATION DOAC Warfarin Compliance Must be good Can be variable Renal function e. GFR > Low e. GFR Dosing No blood tests Regular blood tests Blister Pack Yes More complicated Valve Disease No Yes Metal Valves No Yes Antidote Coming Yes

BONE PROTECTION Consider as primary prevention in those taking long term enzyme inducers including many antiepileptics. Consider in those who are falling. Parenteral preparations available every 6 -12 months

BONE HEALTH ASSESSMENT > Ask about old fractures > Check old x-ray reports for fractures > Do a FRAX score > Start vitamin D if deplete > Falls teams / Physio for education, balance and strength training, bone loading exercises

QUESTIONS joanna. preston@stgeorges. nhs. uk @Geris. Jo @MDTea_podcast