Introduction to the RxFiles
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Optimizing Medications for Older Adults
Julia Bareham & Dr Brian Martens
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September 17, 2015
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RxFiles
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2000: program expanded to provide service to physicians throughout Saskatchewan
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2001: efforts to keep our drug selection tools up to date resulted in the publication of the RxFiles Drug Comparison Charts book
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2011: program expanded to provide services to long‐term care Academic detailing program Not‐for‐profit Funded by a grant from Saskatchewan Health
1997: began as a service to Saskatoon family physicians
This program exists to support health care professionals in making the best possible drug therapy choices for patients.
Value is found in the balanced perspectives on drug effectiveness, safety, cost, clinical evidence & patient considerations.
RxFiles Comparison Chart
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RxFiles Resources
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RxFiles continues to serve health providers and educators through newsletter reviews, Q&As, Trial Summaries, and up‐to‐date drug comparison charts
Tools for the front line practitioner wanting to provide the best possible drug therapy for their patients
www.rxfiles.ca
How much to access?
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Are you a health care provider in Saskatchewan?
Yes? Then, it’s FREE!
www.shirp.ca
PIP (references)
Health Region
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Yes, there’s an app for that!
But wait, there’s more!!!!
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Want to know more?
Patient Case
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E‐mail me!
 julia@rxfiles.ca
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We will come to you!!!
Anywhere in Saskatchewan
In person, or via TeleHealth
Variety of topics to discuss!
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82 year old female
Hypertension (longstanding)
Depression (longstanding)
Constipation (“last few years I’ve struggled”)
Osteoarthritis (affects mostly her knees)
Sleep complaints (“last few years I’ve struggled”)
Complaints of worsening memory (“I’ve noticed it the past few months”)
Urinary incontinence (diagnosed 8 years ago)
Type II Diabetes (diagnosed 3 years ago)
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There’s an app for that!!!
Patient Case
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Serum creatinine: 112 umol/L
Height: 152 cm
Weight: 65 kg
Estimated Renal Function (using CG equation): 35ml/min
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Cholesterol Levels: not available
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Blood Pressure: 127/72
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Renal Function
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EGFR – Now reported on lab results
Cr. Clearance – Not the same but close.
Different formulas
All are estimates!
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What are your
concerns related
to your
medications?
Patient Case
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Metformin 500mg BID
ASA 81mg daily
Atorvastatin 20mg
Sertraline 50mg daily
Colace 100mg BID prn
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Oxybutynin 5mg BID
Amitriptyline 25mg HS
HCTZ 25mg daily
Ramipril 10mg daily
Zopiclone 7.5mg
“Various other OTC products”
Medication Assessment Tips
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Brown bag method
Line up medication with an indication
• Don’t assume an indication by the drug
Watch out for prescribing cascades!
I want to take fewer
medications. I often
wonder if I need all of
them, and it’s costing
me a lot of money each
month.
“Brown Bag Review” of Medications
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Encourages pts to bring all of their medications & supplements to medical appointments
Provides clinical staff with an opportunity to review & discuss the medications that the pt is taking
Reviewing medications with your pt may help you to:
• Answer the pt’s questions
• Verify what the pt is taking (what & how)
• Identify &/or avoid medication errors & DIs
• Assist pt to take medications correctly 5
“Brown Bag Review”
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Did they bring everything?
Drugs from MEC’s
Herbals from Whatever
How often do they take this stuff?
How often is it refilled?
Intelligent non‐adherence
Time‐To‐Benefit (T2B)
Time‐To‐Benefit (T2B)
&
Risk vs Benefit
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Risks
82 year old female
Type II Diabetes (diagnosed 3 years ago)
Glycemic targets
• A1c 6.5%?
• A1c 7.0%?
• A1c 8.5%?
Benefits
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T2B: Examples in Diabetes
Outcomes of Desire??
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↓ cardiovascular events •
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↓ all‐cause mortality
↓ hospitaliza ons
↓ new / worsening nephropathy
↓ re nopathy
↓ neuropathy
↓ foot care complications
UKPDS‐34 (metformin vs standard tx in obese T2DM)
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(MI, stroke, CV death, HF)
Risks
Benefits
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↓ all‐cause mortality NNT=14/10.7 years
↓ stroke NNT=48/10.7 years
A1C achieved was 7.4% vs 8%
~10 years
ADVANCE (mostly gliclazide ± metformin)
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↓ microvascular events NNT=67/5 years
A1C: 6.5 vs7.3
~5 years
Guideline Targets
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Glycemic Targets
Glycemic Targets
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*Priority = Hypoglycemia prevention
Glycemic Targets
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Lack of evidence for tight control
Maybe over time it improves
When individualizing targets, consider:
Limited life expectancy
Functional dependency
Extensive CAD at high‐risk of CV events
Multiple co‐morbidities
History of recurrent, severe hypoglycemia
Hypoglycemia unawareness
Available support & resources Risk vs Benefit
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How well do these drugs even work? 
Oxybutynin 5mg BID
• Antimuscarinic (anticholinergic)
• Urinary incontinence • diagnosed 8 years ago; at age 74
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Risk vs Benefit
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Caution when using this class of medication in older adults!
A retrospective cohort trial in older adult community living centres demonstrated that the benefit of treating with antimuscarinics is almost equal to the risk of causing a hip fracture
• NNT for improved urinary incontinence at 90 days = 32 • 95 % CI 17‐125
• NNH for hip fracture at 90 days = 36 • 95% CI 12‐209
Moga DC, Carnahan RM, Lund BC, Pendergast JF, Wallace RB, Torner JC, Li Y, Chrischilles EA. Risks and benefits of bladder
antimuscarinics among elderly residents of Veterans Affairs Community Living Centers. J Am Med Dir Assoc. 2013 Oct;14(10):74960. doi: 10.1016/j.jamda.2013.03.008.
Risk vs Benefit
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Cochrane review:
• MODEST effect
• May result in 4 less leaks & 5 less voids per week
• This effect may be useful for some, inadequate for others
Nabi G, Cody JD, Ellis G, Herbison P, Hay-Smith J. Anticholinergic drugs versus placebo for overactive bladder syndrome in
adults. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003781.
Applying the Guidelines to Older Adults 9
Blood Pressure Targets
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Harms of sustained too‐high BP seen especially >160mmHg systolic
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Harms of too‐low BP seen especially:
• <60mmHg diastolic for  stroke & CVD risk
• <70‐75mmHg for overall mortality
Not too much, not too little, but just right!
Blood Pressure Targets
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If the older person is dizzy, unsteady or falling, reassess BP meds and BP targets!
Guideline targets >80yrs:
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Blood Pressure Targets
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Do you get dizzy when you get up?
Tired?
<150mmHg over <90mmHg
Individualize the target.
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Risk vs Benefit
Let the target serve the patient, not the patient the target!
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Back to the case…
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HCTZ 25mg daily Ramipril 10mg daily
Blood pressure 127/72
Type II Diabetes
Urinary Incontinence
Anticholinergics
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dry mouth
blurred vision
constipation
drowsiness
sedation
hallucinations
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memory impairment
difficulty urinating
confusion
delirium
decreased sweating
decreased saliva
Back to the case…
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Metformin
Low dose ASA Atorvastatin
Sertraline
Colace
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Oxybutynin
Amitriptyline
HCTZ
Ramipril
Zopiclone
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Shared Decision‐Making
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Genetic & cancer
screening tests?
Respect for the pt’s values, preferences, & expressed needs
Clear, high‐quality information & education for the patient and family
Involves at minimum a clinician & the pt
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Both parties share information
Clinician: offers options & describes their risks & benefits
Pt: expresses his/her preferences & values
Statin everyday for
primary
prevention?
“What matters to you?” as well as “What is the matter?”
Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med. 2012 Mar 1;366(9):780-1.
Shared Decision‐Making
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What is important to the patient?
Patient values
Risk / Benefit
Present Both Sides
• There is data on benefit available from different treatments
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Document!
Decision Aids
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 pt’s awareness & understanding of treatment options & possible outcomes
Online, paper, videos
Can efficiently help patients absorb relevant clinical evidence & aid them in developing & communicating informed preferences
Result of using these tools (Cochrane review):
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 knowledge
More accurate risk perceptions
 # of decisions consistent with pt’s values
 level of internal decisional conflict for pts
Fewer pts remaining passive or undecided
Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med. 2012 Mar
1;366(9):780-1.
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Decision Aids
http://shareddecisions.mayoclinic.org
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Succinct, easy to use tools that provide graphic displays of the benefits & harms of different options organised around concerns that are important to patients
BREAK
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Deprescribing
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 polypharmacy
•  risk of adverse events
•  risk of drug interactions
•  pill burden
•  medication costs
Deprescribing Considerations
Medicines can be grouped as:
1. Those that keep the pt well and improve day‐to‐day QOL
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2. Those that are used for the prevention of illness in the future •
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In some circumstances, the only way to know whether or not to stop a medicine is to actually stop it & see what happens.
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Factors to consider when deciding if a medicine can be stopped include:
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The wishes of the pt
Clinical indication & benefit
Appropriateness
Duration of use
Adherence
The prescribing cascade
e.g. statins, aspirin, warfarin or bisphosphonates
Consider the risks & benefits, T2B, life expectancy
A practical guide to stopping medicines in older people. Best Practice Journal 2012;27
Alexander GC, Sayla MA, Holmes HM, Sachs GA. Prioritizing and stopping prescription medicines. CMAJ 2006;174(8):1083-4.
Deprescribing Considerations
e.g. analgesics, thyroxine or anti‐anginals
In some cases, if these medicines are stopped, the pt may become ill or unable to function. However, some drugs may be able to be stepped down, stopped or used on an as required basis (prn) Deprescribing
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I am a hypocrite!
Need a motivated patient and/or family
Generally successful
Go slow
• Discussion
• Time!
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Review results
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Deprescribing
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Go for the low hanging fruit!
Not Motivated
• Won’t work (Patient values)
• Hardest •
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Metformin
sleeping pills
vitamins
Docusate
Docu‐Don’t
Triple Whammy
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Docusate appears to be no more effective than placebo for 
stool frequency or softening stool consistency
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It does not appear to lessen symptoms associated with constipation (i.e. abdominal cramps) or affect the perceptions associated with completeness of or difficulties with stool evacuation 
http://www.cadth.ca/media/pdf/htis/nov‐
2014/RC0561%20Stool%20Softeners%20Final.pdf
Risk of acute kidney injury when an ACEI or ARB is combined with a diuretic and NSAID Who would take this combo?
• hypertension, congestive heart failure, or renal disease who has arthritis or other mild to moderate pain
PL Detail-Document, The “Triple Whammy.” Pharmacist’s Letter/Prescriber’s Letter. April 2013.
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Zopiclone – New Warning!
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Recommended starting dose has been  to 3.75 mg The lowest effective dose for each pt should be used
The prescribed dose should not exceed 5 mg in elderly pts, in pts with hepatic or renal impairment or those currently treated with potent CYP3A4 inhibitors. Dose adjustment may be required with concomitant use with other CNS‐depressant drugs.
SSRIs – SIADH & GI Bleeds
SIADH & hyponatremia
 Risk factors: SSRIs, diuretics, age, volume depletion
 Sertraline + HCTZ
http://healthycanadians.gc.ca/recall‐alert‐rappel‐avis/hc‐
sc/2014/42253a‐eng.php
SSRIs – SIADH & GI Bleeds
GI Bleeds
 Risk factors: SSRIs, NSAIDs, age
 SSRIs are associated with a modest  in the risk of upper GI bleeding. This risk is significantly elevated when SSRI medications are used in combination with NSAIDs  Setraline + ASA (+OTC Aleve)
Metformin & Renal Function
When to Discontinue, Decrease or Keep Going???
Anglin R, Yuan Y, Moayyedi P, Tse F, Armstrong D, Leontiadis GI. Risk of upper gastrointestinal bleeding with selective serotonin
reuptake inhibitors with or without concurrent nonsteroidal anti-inflammatory use: a systematic review and meta-analysis. Am J
Gastroenterol. 2014 Jun;109(6):811-9.
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What do We Know?
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Almost always the first‐line drug of choice, except possibly for a lean, frail older adult
No RCTs of metformin in the elderly, although clinical experience suggests it is an effective agent
Minimal risk of hypoglycemia
Must be initiated with a low dose & titrated up to minimize GI upset
May be used in individuals with  but STABLE renal function, at a  dose
Metformin & Renal Function
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Adjust dose for renal function! 
Current Canadian and American Guidelines suggest to avoid if CrCl <30ml/min due to risk of lactic acidosis; however, it is rational to have some flexibility with this suggested cut‐off. What do We Know?
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Metformin is a good, useful drug
•  insulin requirements
Cheap!
Does not cause weight gain
Shown to reduce cardiovascular mortality rates in T2DM
Metformin & Renal Function
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Given the outcome benefits seen with metformin, & the rare and controversial concern of its association with lactic acidosis, it is sometimes used cautiously in patients with even lower renal function. •
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Alternative drugs carry their own risks (hypoglycemia with SUs; edema, weight gain, HF & fractures with TZDs) & often less evidence of benefit & safety in this population.
It has been suggested that the risk of death as a result of sulphonylurea (or insulin) induced hypoglycemia in CKD ps
is likely to be greater than the risk of death due to metformin‐associated lactic acidosis.
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Suggested Maximum Dosing of Metformin Based on Renal Function
Monitor renal function at regular intervals (via estimated CrCl)
No renal impairment: ≤ 2550 mg/d
Monitor with normal follow‐up
CrCl 60‐90 ml/min: ≤ 1700 mg/d
CrCl 60‐90 ml/min: Every 6 months
CrCl 30‐60 ml/min: ≤ 850 mg/d
CrCl 30‐60 ml/min: Every 3‐4 months
CrCl < 30ml/min (&/or dialysis): Avoid
N/A
What About Lactic Acidosis?
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Metformin‐induced lactic acidosis
• Rare! 1 to 9 cases/100,000 patient years
• Link could be coincidental rather than causal
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Lactic acidosis risk factors:
• Conditions that cause hypoxemia
• Acute Cardiovascular Condition– heart failure
• Acute Renal Condition – contrast media for diagnostic purposes
• Acute Hepatic Condition – severe hepatic dysfunction
• Respiratory failure
• Sepsis
• Hypovolemia
RxFiles Q&A Metformin: Precautions with Renal Impairment, Hepatic
Disease and Heart Failure
Lactic Acidosis
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Life‐threatening event (40‐50% death rate)
Onset is subtle, accompanied by non‐specific symptoms:
• Malaise
• Myalgias
• Respiratory distress
•  somnolence
• Abdominal distress
Labs:
• Low pH
•  anion gap
• Elevated blood lactate
Meds to Hold in Acute GI Illness
Medications/Medication Classes to Hold in Acute GI Illness
 risk for a decline in renal function
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Sulfonylureas (i.e. gliclazide Diamicron, glimepiride Amaryl, glyburide Diabeta)
A
ACE‐inhibitors (e.g. lisinopril Zestril, Prinivil, perindopril Coversyl, ramipril Altace) 
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Diuretics
(e.g. hydrochlorothiazide, furosemide Lasix)
Direct renin inhibitors (i.e. Aliskiren Rasilez)
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Metformin
 clearance leading to 
risk of adverse events
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Glucophage, Glycon
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Angiotensin receptor blockers
(e.g. candesartan Atacand, valsartan Diovan) 
N
NSAIDs (e.g. ibuprofen Advil, naproxen Aleve) & COXIBs (e.g. celecoxib Celebrex)
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And now for a little musical interlude…
https://www.youtube.com/watch?v=Lp3pFjKoZl8
CDA 2013
http://guidelines.diabetes.ca/CDACPG_resources/Appendices/Appendix_7.pdf
Improving Communication
Amongst the Interdisciplinary
Team
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I am no expert
Team Conferences (Long‐Term Care)
Team Conferences
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Problems – Time, Time, Time, Time, Time, etc.
Hard to do even one per year
Ministry of Health mandates 4 per year
Impossible
• Best time for discussion between groups
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Care By Design
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From Halifax
Dr. assigned to a Unit / Floor (25 residents)
Weekly scheduled review times
Paramedic support
Evidence‐based guidelines
Sources of Information
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Best Science Medicine podcast
RxFiles
InfoPoems podcast
Cochrane Review podcast
“A Bitter Pill” by Dr. John Sloan
Need to Change!
Phone a friend. Or text. Or e‐mail. Or fax.
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druginfo@usask.ca
(306) 966‐6340 [Saskatoon]
1‐800‐667‐DIAL (3425) Text: (306) 260‐3554
Fax: (306) 966‐2286
http://medsask.usask.ca/
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Questions??
julia@rxfiles.ca
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