Nursing Facility Inservice
Reducing the Use of
Inappropriate Medications
Propoxyphene (Darvocet, etc.)
&
Medications with Anticholinergic
Effects
Fleetwood Toolkit v 1.0 (11/05)
Reducing the Use of Inappropriate
Medications
• [INSERT PHARMACY NAME] is implementing new
procedures to address the use of medications
potentially inappropriate for use in the elderly
• Initial focus is on propoxyphene (e.g., Darvon,
Darvocet, Wygesic) and medications with
anticholinergic effects
• Goal is to reduce new orders for potentially
inappropriate medications and increase monitoring
for adverse effects where suitable alternatives are
not available
• This should result in improved patient care and
documentation required for survey process
Fleetwood Toolkit v 1.0 (11/05)
Propoxyphene Product Alert
(Darvon, Darvocet N, Darvocet A 500, Wygesic)
• Propoxyphene is inappropriate for use in
elderly patients due to its adverse effects
and questionable efficacy
• Studies have demonstrated that
propoxyphene is no more effective than
acetaminophen (Tylenol) or aspirin in
reducing pain, and in most studies was
less effective
Fleetwood Toolkit v 1.0 (11/05)
Number of Double-blind Studies
Propoxyphene (Darvon, etc.) vs
Aspirin or Acetaminophen
7
6
5
4
Propoxyphene
Questionable Efficacy
3
2
1
0
ASA or
acetaminophen
more effective
than
propoxyphene
7 studies
ASA or
acetaminophen
equal to
propoxyphene
1 study
ASA or
acetaminophen
less effective than
propoxyphene
No studies
Fleetwood Toolkit v 1.0 (11/05)
Estimated Cost of a Single Week of
q4h Therapy
$7.00
$6.00
$5.00
Propoxyphene
More Costly
$4.44
$6.59
$4.62
$4.00
$3.06
$3.00
$2.00
$1.00
$1.00
$0.42
$0.00
Fleetwood Toolkit v 1.0 (11/05)
$5.07
What makes propoxyphene
inappropriate for elderly patients?
• CNS Side Effects
– Dizziness, Sedation, Drowsiness, Confusion
– May increase risk for falls
• Research has identified propoxyphene use as a risk factor for
hip fractures
• Other Adverse Effects
–
–
–
–
Poor appetite
Nausea, vomiting
Trouble urinating or emptying bladder
Constipation
Fleetwood Toolkit v 1.0 (11/05)
What makes propoxyphene
inappropriate for elderly patients?
• Active metabolite has cardiotoxic, arrhythmic
effects, and CNS toxicities
• Active metabolite has long elimination half-life of
30-36 hours, which poses high risk of
accumulation if given repeatedly
• Older adults are especially prone to increased
serum concentrations or reduced elimination of
propoxyphene
• Note: There is a 50% decline in renal (kidney)
clearance of medications in people age 75 and
older
Fleetwood Toolkit v 1.0 (11/05)
Propoxyphene and RAPs
• Propoxyphene may cause, aggravate, or
contribute to the following RAP problems due to
its adverse effects:
1. Delirium
2. Cognitive Loss/Dementia
3. Visual Function
4. Communication
5. ADLs
6. Urinary Incontinence
8. Mood State
9. Behavioral Symptoms
11. Falls
15. Dental Care
Fleetwood Toolkit v 1.0 (11/05)
Alternatives to Propoxyphene
for Episodic (non-continuous) Pain
• Mild to Moderate Pain
– Acetaminophen is drug of choice
– Pain not controlled by acetaminophen is
unlikely to be controlled by propoxyphene
– Traditional NSAIDs should be avoided in
patients who require long-term daily analgesic
therapy
• Moderate to Severe Pain
– Hydrocodone (Vicodin) prn
Fleetwood Toolkit v 1.0 (11/05)
Propoxyphene Alert
[Pharmacy] Procedures
• Propoxyphene Alert Letter
– Sent to prescribers for all new propoxyphene
orders with recommendation for alternative
therapy
• Propoxyphene Alert Card (see example)
– Sent by pharmacy for all propoxyphene refills
– Punch hole in card and place in front of patient’s
MAR
• Contact your Consultant Pharmacist for any
questions
Fleetwood Toolkit v 1.0 (11/05)
What You Can Do
• Mild or moderate pain
– Do not encourage or recommend propoxyphene
– Episodic pain: Acetaminophen 650mg po q4h prn pain.
– Continuous pain: Acetaminophen 650mg po q4h. Do not
exceed 4000mg per day.
• Moderate to severe pain not controlled by
acetaminophen
– Episodic pain: Hydrocodone prn
– Continuous pain: Hydrocodone
• A prophylactic bowel regimen should be initiated with the
commencement of persistent opioid therapy
• For patients receiving propoxyphene
– Monitor for adverse effects and document if observed
– Report adverse effects to prescriber
Fleetwood Toolkit v 1.0 (11/05)
Pain Management
• For chronic, severe, or uncontrolled pain,
contact your Consultant Pharmacist for
therapy recommendations
Fleetwood Toolkit v 1.0 (11/05)
Anticholinergic Alert
• Many medications are potentially inappropriate for
use in elderly patients due to their anticholinergic
effects
– For some of these medications, there are no suitable
alternatives
• Anticholinergic side effects are among the most
common drug-related effects experienced by elderly
nursing facility residents
• It is important to know commonly used medications
with anticholinergic effects
• Anticholinergic adverse effects may be more likely or
severe if the patient is receiving several medications
with anticholinergic effects
• Observe patient for adverse effects so problems can
be avoided, managed, or reversed
Fleetwood Toolkit v 1.0 (11/05)
Symptoms of Anticholinergic Effects
• Dry or sticky lips; difficulty beginning to speak (need to lick
lips first)
• Urinary disorders, necessitating use of catheter
• Dry, pale, cool skin
• Insecure movement; falls without obvious reason
• Blurred vision
• Increased anxiety, with rapid shallow breathing, tachycardia
(rapid heart rate), cardiac arrhythmias
• Drowsiness, sedation
• Fatigue, weakness
• Constipation
• Memory impairment, confusion, disorientation
• Hallucinations, delirium
Fleetwood Toolkit v 1.0 (11/05)
Spectrum of Anticholinergic Side Effects
Mild
Moderate
Severe
Dryness of mouth
Thirst
Speech problems
Reduced appetite
Difficulty chewing, swallowing, speaking
Impaired perception of taste/ texture of food
Mucosal damage; Dental decay, denture misfit
Malnutrition
Dilation of pupils
Vision disturbances
Dizziness
Increased risk of falls
Exacerbate acute angle glaucoma
Constipation
Fecal impaction
Paralytic ileus, pseudo-obstruction
Reduced gastric
secretions/emptying
Altered absorption of medications
Urinary hesitancy
Urinary retention, UTI
Increased heart rate
Decreased sweating
Conduction disturbances, supraventricular tachycardia
Exacerbation of angina
Congestive heart failure
Hyperthermia
Drowsiness
Fatigue
Excitement
Restlessness
Profound restlessness, disorientation, agitation
Mild amnesia
Inability to concentrate
Confusion
Memory impairment
Hallucination, delirium
Exacerbation of cognitive impairment
Ataxia, muscle twitching, seizures
Fleetwood Toolkit v 1.0 (11/05)
Anticholinergics and RAPs
• Medications with anticholinergic effects may cause,
aggravate, or contribute to the following RAP problems
due to adverse effects:
1. Delirium
2. Cognitive loss/Dementia
3. Visual Function
4. Communication
5. ADLs
6. Urinary Incontinence
8. Mood State
9. Behavioral Symptoms
11.Falls
15.Dental Care
Fleetwood Toolkit v 1.0 (11/05)
Medications with Anticholinergic Effects
Anti-nausea/dizziness
promethazine (Phenergan)
prochlorperazine (Compazine)
trimethobenzamide (Tigan)
meclizine (Antivert)
cyclizine (Marezine)
Antihistamines
diphenhydramine (Benadryl)
chlorpheniramine (ChlorTrimeton)
hydroxyzine (Atarax/Vistaril)
cyproheptadine (Periactin)
Urinary and
GI Antispasmodics
Oxybutynin (Ditropan)
flavoxate (Urispas)
dicyclomine (Bentyl)
hyoscyamine; belladonna
alkaloids; clindinium;
propantheline
Antiparkinson
benztropine; biperiden;
procyclidine; trihexyphenidyl;
ethoproprazine
Muscle Relaxants
metaxalone (Skelaxin)
cyclobenzaprine (flexeril)
orphenadrine (Norflex)
Antiarrhythmics
disopyramide (Norpace)
procainamide (Pronestyl)
quinidine
Antidepressants
amitriptyline (Elavil)
doxepin (Sinequan)
imipramine (Tofranil)
trimipramine (Surmontil)
nortriptyline (Pamelor)
protriptyline (Vivactil)
amoxapine (Asendin)
maprotiline (Ludiomil)
clomipramine (Anafranil)
Anti-migraine
belladonna alkaloids
Antipsychotics:
chlorpromazine (Thorazine)
thioridazine (Mellaril)
clozapine (Clozaril)
fluphenazine (Stelazine)
thiothixene (Navane)
Antidiarrhea
Lomotil
Fleetwood Toolkit v 1.0 (11/05)
Anticholinergic Alert
[Pharmacy] Procedures
• Direct communication with prescriber;
recommendation for safer alternative
• Anticholinergic Alert Form (see example)
– Completed by Consultant Pharmacist as part of drug
regimen review for new orders
– Indicates all medications with anticholinergic effects
that patient is receiving
• Anticholinergic Alert Card (see example)
– Sent by pharmacy with all refills for medications with
anticholinergic effects
– Punch hole in card and place in front of patient’s MAR
• Contact your Consultant Pharmacist for any
questions
Fleetwood Toolkit v 1.0 (11/05)
What You Can Do
• Become familiar with symptoms of
anticholinergic effects and the medications
that cause them
• Note when patient is receiving more than one
medication with anticholinergic effects
• Monitor for adverse effects and document if
observed
• Resist temptation to request additional
medication to treat symptoms of
anticholinergic effects
– Contact Consultant Pharmacist to resolve
medication-related problems
Fleetwood Toolkit v 1.0 (11/05)