Polypharmacy
Jillian Hernan Fee, PharmD, BCPS
Clinical Pharmacist
CarePro Home Infusion
April 25, 2014
Polypharmacy, what is it?
• Poly (Greek) = Many
• Pharmacy = Drugs/Medications
• What does many drugs mean?
– How many meds are too many?
• Example 1 – 75 yom with CHF, CAD, DM, HTN,
HLP
• Example 2 – 82 yof with dementia and overactive
bladder
CarePro Pharmacist Poll
• Using multiple pharmacies, providers, and prescription
drugs that may not be appropriately monitored (3)
• Using multiple medications either for same condition
or to treat side effects of another drug (7)
• Using multiple medications that are not clinically
indicated (1)
• Unnecessary use of meds when fewer meds or other
options may be more appropriate (1)
• Using more than one pharmacy to fill rx meds (may be
drug seeking behavior)
• Using more than 5-7 medications (4)
– Number of meds changed with RPh
Polypharmacy definition
Bushardt 2008
Polypharmacy definition
• Most common in literature:
– Medication does not match diagnosis (4)
– Many medications, duplication of medications, drug-drug
interactions (3)
– Inappropriate dosing frequency (excessive duration, dose
too low, dose too high), medication prescribed to treat a
side effect (2)
– The term “inappropriate” often occurs in definitions
– Number of medications taken routinely
• “Hyperpharmacotherapy”
– Excessive use of drugs for treatment of disease
• Not really used mainstream but I like this term
• Carries a negative connotation
• Medication Underutilization
– Omission of an indicated and potentially beneficial
medication for the treatment or prevention of disease
Bushardt 2008, Barry 2007, Wright 2009
Consequences of polypharmacy
• CMS estimates $50 billion annually
• Adverse drug reactions
– Risk increases with multiple comorbidities,
use of high risk drugs (ie warfarin), and
increasing numbers of meds
• Adherence
– ADR’s
– Complex regimens
Bushardt 2008, Hajjar 2007
Consequences of polypharmacy
• Inappropriate prescribing
– More meds = higher risk
– Beers’ list meds
– Drug interactions
– Is the medication list complete and correct?
• Geriatric Syndromes
– Increased risk of cognitive impairment
– Increased risk of falls
• Morbidity/Mortality
Hajjar 2007, Agostini 2004
Who is at risk?
Kaufman 2002
Who is at risk?
Kaufman 2002
Who is at risk?
• Demographic
– Age, caucasian race, education
• Health status
– Poorer health, use of >8 medications
– Diagnosis of: HTN, anemia, asthma, angina, diverticulitis,
arthritis, gout, DM
• Access to health care
– Multiple providers, number of health care visits,
supplemental insurance
• Underutilization
– Increased severity of comorbid conditions
– Physical limitations
– Caucasian race
Hajjar 2007, Wright 2009
Why elderly?
• Physiological changes
– Decreased renal function
– Decreased hepatic function
– Decreased total body water and lean body
mass
– Decreased vision/hearing
• Lack of clinical trials in elderly patients
Bushardt 2008
Prevalence of polypharmacy
• Steinman 2006
– Evaluated 196 patients taking 1,582
medications
– 65% of patients were taking one or more
inappropriate meds
– 64% missing beneficial meds
– 42% taking inappropriate meds AND were
missing beneficial meds
– 13% had appropriate therapy!!
Prevalence of polypharmacy
• Hajjar 2005
– 384 frail, elderly patients’ medication
regimens evaluated at hospital discharge
– 44% had at least one unnecessary drug
• Almost 75% of these patients were on this
unneeded drug prior to hospitalization
– 18% had 2 or more inappropriate meds
Prevalence of underutilization
• Wright 2009
– 384 frail, elderly patients’ medication
regimens evaluated at hospital discharge
– 62% (238 patients) were missing a potentially
beneficial medications
• 87.3% of these patients were missing this drug
prior to hospitalization
– 25.8% (99 patients) were missing 2 or more
medications
Assessments
• Beers’ List
• Medication Appropriateness Index
• STOPP
– Screening Tool of Older Persons’ potentially
inappropriate Prescriptions
• Hyperpharmacotherapy Assessment Tool
• START
– Screening Tool to Alert doctors to the Right
Treatment
• Assessment of Underutilization Index
• Geriatric Evaluation
Beers’ List
• Originally pusblished in 1991 for residents of
nursing homes
• Lists of medication considered potentially
inappropriate medications in elderly patients
1. Drugs to avoid in elderly
2. Drugs to avoid in elderly with certain disease states
3. Drugs to be used with caution in the elderly
• Intended as a guideline only, using these meds in
elderly is not automatically inappropriate
• See handout
Fick 2012
Beers’ List
• Notable 2012 changes
– Medications/classes to avoid
• Glyburide, megestrol, sliding scale insulin
– Medications/classes to avoid in certain disease
states
• Heart failure – thiazolidinediones (glitazones)
• History of syncope – acetylcholinesterase inhibitors
• Falls/fractures – SSRI’s
– Medications/classes to use with caution
• Prasugrel (Effient), Dabigatran (Pradaxa)
– Greater risk of bleeding in the elderly
Fick 2012
Medication Appropriateness Index
• Evaluates each medication individually
based on 10 criteria for appropriateness
• Limitations:
– Time (10 minutes/drug)
– Full scope of ADR’s not included
• Assesses drug-drug or drug-disease interactions
but not side effects independently
– Adherence is not addressed
Hanlon 1992
Hanlon 1992
Summated MAI
• Attempted to quantify the level of
inappropriateness
• Grouped questions in MAI by level of
importance
– Group A: indication and effectiveness
– Group B: dosage, correct directions, drug-drug
and drug-disease interactions
– Group C: practical directions, expense,
duplication, and duration
• Limitations – same as for MAI
Samsa 1994
STOPP
• Screening Tool of Older Persons’
potentially inappropriate Prescriptions
• Developed in Europe
• Potentially inappropriate medications are
listed by organ system
– Focused on meds commonly used in geriatric
population in Europe
• See handout
Gallagher 2008 (Clin Pharmacol Ther)
Hyperpharmacotherapy
Assessment Tool
• Suggest annual review (at minimum)
• Form is set up based on various goals
– I. Number of meds
– II. Decrease inappropriate meds
• Meeting goals, disease still present?, least expensive option,
Beers List med?
– III. Decrease inappropriate pharmacology
• Duplications, combo meds, ADR’s, interactions
– IV. Optimize dosing regimen
• Is this is the lowest effective dose? Any meds taken more than
BID? Adherence issues?
– V. Organize sources of meds
• More than one pharmacy? Mail order? Other prescribers?
– VI. Patient education
Bushardt 2008
Assessment of Underutilization
Jeffery 1999
START
• Screening Tool to Alert doctors to the
Right Treatment
• Developed in conjunction with STOPP
guidelines in Europe
• Meds are screened by organ system
• See handout
Gallagher 2008 (Clin Pharmacol Ther)
Specialized Geriatric Evaluation
• Integrated team of geriatricians, social workers,
nurses, and other healthcare providers evaluate
medication use in both inpatient and outpatient
setting
• Study done at several VA centers
– Assessed 834 frail, elderly veterans for adverse drug
reactions and suboptimal prescribing in both
outpatient clinics and as inpatients compared with
usual care
– Primary outcome: adverse drug reactions
• Both any ADR and serious ADR’s were assessed
– Results: outpatient clinics but not inpatient units
reduced the risk of serious ADR’s
Schmader 2004
How well do evaluations work?
• Gallagher 2011
– Evaluated 382 patients randomized to usual care or
evaluation with STOPP/START criteria from hospital
admission to 6 months after discharge
– Primary outcomes: change in MAI and AOU scores
– Results
• MAI – 71.1% of intervention and 35.4% of control group had
improved MAI score on hospital discharge
– Absolute risk reduction 35.7%
– Number needed to screen: 2.8 (95%CI 2.2-3.8)
• AOU – 31.6% of intervention and 10.4% of control group had a
reduction in AOU score on hospital discharge
– Absolute risk reduction 21.2%
– Number needed to screen: 4.7 (95%CI 3.4-7.5)
– The rate of potentially inappropriate prescribing increased
gradually during the 6 month follow up period – authors
conclude that patients should be assessed at least every 6
months
How well to evaluations work?
• STOPP vs Beers’ List
– Evaluated 715 admissions of elderly patients
– Trained clinicians identified patients who’s admission
were due to adverse effects
• The number of potentially inappropriate meds identified by
the 2 evaluations were compared
– Results
• All drugs
– STOPP: found inappropriate meds in 35% of patients
– Beers’ List: found inappropriate meds in 25% of patients
• Admissions due to ADR’s (N=90)
– STOPP: identified 91% (82 pts) of the meds as inappropriate
– Beers’s List: identified 48% (43 pts) of the meds as inappropriate
Gallagher 2008 (Age and Ageing)
How to appropriately stop meds
• Do not stop more than 1 drug at a time
– Some meds require tapering off and careful
monitoring during the taper period
– Attempt to make changes over a longer
period of time
• Consider use of midlevel practioners for
follow up visits and monitoring
Bushardt 2008
Role of the dietician
• Grapefruit interactions
• Ask patient what their meds are for
• Remind patients
– Take med list to every provider visit
– Update the list with every visit
– Tell all providers about all meds, including
OTC and herbal meds
Agostini JV, Han L, Tinetti ME. The relationship between number of
medications and weight loss or impaired balance in older adults. J Am
Geriatr Soc. 2004;52:1719-1723.
Barry PJ, Gallagher CR, O’Mahony D. START (screening tool to alert doctors to
the right treatment)- an evidence based screening tool to detect
prescribing omissions in the elderly. Age Ageing. 2007;36:632-638.
Bushardt RL, Massey EB, Simpson TW, et al. Polypharmacy: misleading, but
manageable. Clin Int Aging. 2008:3(2) 383-389.
Fick D, Semla T, Beizer J, et al. American Geriatrics Society updated Beers
criteria for potentially inappropriate medication use in older adults. J Am
Geriatr Soc. 2012;60:616-631.
Gallagher PF, O’Connor MN, O’Mahony. Prevention of potentially inappropriate
prescribing for elderly patients: a randomized controlled trial using
STOPP/START criteria. Clin Pharm Ther. 2011;89(6):845-854.
Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially
inappropriate Prescriptions): application to acutely ill elderly patients and
comparison with Beers’ criteria. Age and Ageing. 2008;37:673-679.
Gallagher P, Ryan C, Kennedy J, et al. STOPP (Screening Tool of Older
Persons’ potentially inappropriate Prescriptions) and START (Screening
Tool to Alert doctors to the Right Treatment). Consensus validation. Int J
Clin Pharmacol Ther. 2008;46(2):72-83.
Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am
J Geriatr Pharmacother. 2007;5:345-351.
Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary drug use in frail
older people at hospital discharge. J Am Geriatri Soc.
2005;53:1518-1523.
Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing
drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):10451051.
Jeffery S, Ruby C, Twersky J, et al. Effect of an interdisciplinary team
on suboptimal prescribing in a long-term care facility. Cons Pharm.
1999;14:1386-1391.
Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of
medication use in the ambulatory adult population of the United
States: The Slone Survey. JAMA. 2002;287:337-344.
Samsa GP, Hanlon JT, Schmader KT, et al. A summated score for the
medication appropriateness index: development and assessment
of clinimetric properties including content validity. J Clin Epidemiol.
1994;47(8):891-896.
Schmader KE, Hanlon JT, Pieper CF, et al. Effects of geriatric
evaluation and management on adverse drug reactions and
suboptimal prescribing in the frail elderly. Am J Med.
2004;116:394-401.
Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy
and prescribing quality in older people. J Am Geriatr Soc.
2006;54:1516-1523.
Wright RM, Sloane R, Pieper CF, et al. Underuse of indicated
medications among physically frail older US veterans at the
time of discharge: results of a cross-sectional analysis of data
from the geriatric evaluation and management drug study. Am
J Geriatr Pharmacother. 2009;7:271-280.