#56: Polypharmacy and deprescribing Part 1: Living better through chemicals

September 11, 2017 | By Matthew Watto, MD

Avoid common pitfalls, recognize prescribing cascades, and deprescribe like a champ with tips from Clinical Pharmacist, Dr. Sean M. Jeffery, Clinical Professor of Pharmacy at the University of Connecticut School of Pharmacy, and Chair of the Polypharmacy Special Interest Group for the American Geriatrics society. We discuss how to create better medication lists, tools and tips for deprescribing, how to counsel patients on polypharmacy, and safe use of medication in the elderly.

Special thanks to the American Geriatrics Society for setting up this interview.

Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Case from Kashlak Memorial: 80 yo F with early (mild) dementia, heart failure, atrial fibrillation, chronic kidney disease, obesity, diabetes, and hypertension who presents with complaint of knee pain. You count a total of 22 total meds and supplements. Fourteen of these are daily “mandatory” meds and and seven are as needed.

Clinical Pearls:

1. Polypharmacy = too many meds that aren’t aligned with patient’s goals of care and/or are inappropriate. No specific numerical cutoff defines polypharmacy.
2. Prescribing cascade: One medication’s side effects leads to prescription of a new medication to treat those side effects, and on, and on, and on…
3. Deprescribing = Active removal of inappropriate, harmful, or ineffective medications. Dr. Jeffery recommends one change per visit (ideally).
4. 5 steps of deprescribing: 1. List all drugs a patient takes and reasons for each. 2.  Consider overall risk of drug-induced harm for your patient to determine the required intensity of deprescribing. 3. Assess each drug for current/future benefit/harm. 4.  Prioritize drugs for discontinuation by benefit-harm ratio and likelihood of adverse from withdrawal. 5. Monitor for improvement in outcomes or onset of adverse effects (Scott et al JAMA Int Med 2015).
5. Making better medication lists: 1. Make sure you have an accurate list. 2. Give list to the patient. 3. Ask about OTC meds and supplements. 4. Group medications by indication 5. Make sure all meds have an indication 6. Assess effectiveness of each medication.
6. Anticholinergic side effects: Commonly implicated meds are listed in Beers list. Mnemonic = Blind as a bat, dry as a bone, red as a beet, hot as a hare, mad as a hatter (see image on Sketchy Medicine).
7. Bladder medications: Lots of advertising, but poor evidence (see episode #53 Urinary incontinence). Decrease frequency and incontinence by about one episode per day.
8. Questions to ask: Patients and providers differ in perception of which meds are most important. Ask patients: What is the most important medication to you? What medication would you most like to stop?
9. Living medication list: Accurate med list that is updated in real time and tracks across electronic records/health systems. An aspirational goal that doesn’t yet exist.
10. Dosing in CKD: Use Cockcroft Gault, then add and subtract 5 to number and use a range (Dr. Jeffery’s expert opinion).
11. Insomnia: No sleep meds are safe in the elderly. Life hacks: Take a walk in the early morning for circadian rhythm. Avoid meds that cause insomnia.

Goal: Listeners will define, and recognize polypharmacy; recognize steps required for deprescribing; identify culprit medications, and avoid adverse events.

Learning objectives:
After listening to this episode listeners will…

1. Define polypharmacy, deprescribing, and prescribing cascade
2. Develop better medication lists
3. Evaluate a patient’s medication list and recognize inappropriate prescribing
4. Counsel patients on polypharmacy and deprescribing
5. Identify common drug-drug and drug-disease interactions
6. Become familiar with tools for safe prescribing
7. Safely dose medications in chronic kidney disease

Disclosures:
Dr. Jeffery reports no relevant financial disclosures.

Time Stamps
00:00 Intro
01:12 Listener feedback
01:56 Picks of the week
06:28 Topic intro and guest bio
07:49 Getting to know our guest
13:05 Defining polypharmacy and related terms
16:30 Clinical Case of polypharmacy
20:34 Making better medication lists
25:01 Clinical Case from Kashlak Memorial
28:40 Beers Criteria
35:41 Statins in frail, elderly patients
38:00 Treating insomnia in the elderly
44:15 Dosing of meds in patients with CKD
45:50 Tool for analysis of drug-drug interactions
48:10 Take home points from Dr. Jeffery
50:00 Outro

Links from the show:

1. JAMA Clinical Reviews Podcast
2. Explore the Space – Mark Shapiro
3. Neil Breen: Fateful Findings (film) on YouTube
4. Sharknado 4 (film)
5. Smoke Gets in your Eyes and Other Lessons from the Crematory (book) by Caitlin Doughty
6. MicroMedix and Lexicomp apps
7. Medication appropriateness index. J Clin Epidem 1994
8. Safety and Benefit of Discontinuing Statin Therapy in the Setting of Advanced, Life-Limiting Illness. JAMA Int Med 2015
9. The effects of melatonin versus placebo on delirium in hip fracture patients: study protocol of a randomised, placebo-controlled, double blind trial. BMC Geri 2011
10. Beers Pocket Card from the American Geriatric Society 2015
11. J Am Geriatr Soc. 2015 Nov;63(11):2227-46. doi: 10.1111/jgs.13702. Epub 2015 Oct 8. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.  By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel.
12. JAMA Intern Med. 2016 Apr;176(4):482-3. doi: 10.1001/jamainternmed.2015.8597. Polypharmacy-Time to Get Beyond Numbers.  Steinmain, MA.
13. JAMA Intern Med. 2016 Apr;176(4):473-82. doi: 10.1001/jamainternmed.2015.8581. Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011.  Cato DM, et al.
14. Estimating Creatinine Clearance in the Elderly: To Round or Not to Round? by Michael J. Postelnick, BSPharm on Medscape
15. JAMA. 2016 Mar 8;315(10):1034-45. doi: 10.1001/jama.2016.0299. Polypharmacy in the Aging Patient: A Review of Glycemic Control in Older Adults With Type 2 Diabetes.  Lips KJ, et al.
16. JAMA. 2015 Jul 14;314(2):170-80. doi: 10.1001/jama.2015.7517. Polypharmacy in the Aging Patient: Management of Hypertension in Octogenarians.  Bents A , et al.
17. South Med J. 2015 Feb;108(2):97-104. doi: 10.14423/SMJ.0000000000000243. Rules for improving pharmacotherapy in older adult patients: part 1 (rules 1-5).  Wooten JM.
18. South Med J. 2015 Mar;108(3):145-50. doi: 10.14423/SMJ.0000000000000257. Rules for improving pharmacotherapy in older adult patients: part 2 (rules 6-10).  Wooten JM.
19. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015
20. Donepezil and memantine for moderate-to-severe Alzheimer’s disease. NEJM 2012