#57: Polypharmacy and deprescribing Part 2: More thinking and thoughts

September 15, 2017 | By Matthew Watto, MD

Improve your prescribing practices with tips from The Curbsiders as Matt, Stuart and Paul “Pwilliams” discuss safe prescribing in frail, older adults with diabetes, chronic kidney disease, hypertension, and/or dementia in this part two episode on polypharmacy and deprescribing.

Full show notes available at http://thecurbsiders.com/podcast

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Clinical Pearls:

1. Diabetes: A1C goal 7-7.5% for healthy older adults, 7.5-8% if moderate comorbidity and < 10 years life expectancy, and 8-9% if limited life expectancy (from AGS Choosing Wisely). An A1C <7 (or 6.5%) in the elderly is okay if done safely.
2. Hypertension = Check standing blood pressure to assess for orthostatic hypotension. One minute is probably sufficient to determine risk (NEJM Journal Watch 2017). Use more lenient goal <150/90 in frail elderly.
3. Chronic kidney disease: Utilizing the same equation used in phase 3 clinical trial for a given medication is probably too complicated. For now, we recommend picking an equation, then assuming eGFR (or CrCl) is +/- 5 points from calculated value.
4. Dementia: Donepezil improves Mini Mental Status examination score by about 1.5 points. Clinical significance/benefit is questionable, but a 3 month trial with close monitoring for side effects of nausea, urinary incontinence, bradycardia, and weight loss is recommended (from AGS Choosing Wisely).

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:
The Curbsiders report no relevant financial disclosures, but hope to have a long list of disclosures in the future ; )

Links from the show:

1. American Geriatrics Society Ten Things Clinicians and Patients Should Question – Choosing Wisely 2013
2. No Need to Wait 3 Minutes After Standing to Assess Orthostatic Hypotension. NEJM Journal Watch 2017
3. 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.
4. JAMA Intern Med. 2016 Apr;176(4):482-3. doi: 10.1001/jamainternmed.2015.8597. Polypharmacy-Time to Get Beyond Numbers.  Steinmain, MA.
5. 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.
6. Estimating Creatinine Clearance in the Elderly: To Round or Not to Round? by Michael J. Postelnick, BSPharm on Medscape
7. 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.
8. 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.
9. 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.
10. 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.
11. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015
12. Donepezil and memantine for moderate-to-severe Alzheimer’s disease. NEJM 2012
13. https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/herbs/search