Polytherapeutics-Dr Rapp by xl771209

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									Prescribing for Old Age
“A little poison now and then makes for agreeable dreams, and much poison in the end for an agreeable death”

Neitzsche

Polypharmacy
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Duplicative indications

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Drug-drug interactions
Inadequate attention to pharmacokinetics and pharmacodynamic principles

David Hayes Pharm D, UH College of Pharmacy

The Prescribing Cascade
INITIAL CONDITION THERAPY NEW SYMPTOM SUBSEQUENT

ARTHRITIS

NSAID

 BP
ANTI HTN

DEMENTIA

CHOLINESTER ASE Inhibitor
INCONTINENCE ANTICHOL INERGIC

AGITATION
ANTIPSYCHOTIC

EPS
PARKINSON MED

Gurwitz JH. P&T. 1997

Polytherapeutics
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the ART of using medications for the treatment of co-morbid conditions

David Hayes Pharm D, UH College of Pharmacy

Co-morbid Disease in the Older Adult…..
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Community: seven (7) medical conditions Nursing Facility: eleven (11) medical conditions Clinical trials usually exclude subjects with comorbid states Treatment guidelines have not included comorbid considerations
Beers M.H. Consult Pharm 1999

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…..Co-morbid Disease
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Relationships of Co-morbid Disease and Pharmacotherapy
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Drug induced disease Drug is indicated for  1 disease state Drug is indicated for one disease state but contraindicated for  1 other disease state Pharmacokinetic or pharmacodynamic characteristic of drug is altered by disease state Drug-drug interaction when two indicated drugs are used for 2 different disease states

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Pharmacokinetic Changes in the Older Adult
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Absorption Distribution Metabolism Elimination

David Hayes Pharm D, UH College of Pharmacy

Beer’s Criteria
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Consensus Panel Updated 2003 Severity ratings High or Low Problems given the Disease Concerns independent of Disease

Fick, et al. (2003), Arch Intern Med, 163(22), 2716-2724.

Disease Specific Interactions
Heart Failure
Bladder outlet obstruction Stress UI

Syncope

Disopyramide [Norpace] Tolterodine [Detrol] Alpha blockers [Cardura] Tricyclics [Pamelor]

Exacerbates failure
Retention Worsens UI

Falls, syncope

Problems Independent of Disease
Propoxyphene [Darvocet] Meperidine [Demerol]
Diphenydramine

Same relief as Same S.E. as acetaminophen narcotics Confusion Not effective orally

[Benadryl] Cimetidine [Tagamet]

Confusion, Don’t use as falls, retention sedative
Confusion Safer alternatives

Drug Regimen Review Summary
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Brown Bag Review Over the Counter Drugs [OTC’s] Costs and Adherence Beer’s List Side Effects

Tool Kit for Drug Regimen Review
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Beers List1 Multidisciplinary Medication Management Tool Kit2 Quality Indicators for Chronic Disease3

1. Fick (2003), 2. American Medical Directors Association, American Society of Consulting Pharmacists 3. Saliba, Solomon, Rubenstein, Young, Schnelle, Roth, et. Al (2004)

Drug Regimen Review Brown Bag
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What do you buy in the pharmacy or grocery store without a prescription? What do you buy in the health food section? How often do you take this? Who else prescribes for you?

Drug Regimen Review OTC
Pain or headache Laxative Vitamins Insomnia NSAIDS = dyspepsia Bulk forming ↓ digoxin Iron ↓ thyroid preparations Diphenhydramine ↑ zolpidem [Ambien] Diphenhydramine = urinary retention

Cough/cold

Drug Regimen Review Adherence
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Are you able to fill them each month? Are you having difficulty filling your prescriptions? Would you be willing to take a drug more often if it was less expensive? Finger stick testing is expensive, are you trying to conserve supplies?

Beer’s List
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IF the resident has congestive heart failure THEN stop disopyramide [Norpace] IF there is peripheral vascular disease THEN stop metoclopramide and beta blockers IF there is constipation THEN stop anticholinergic, narcotics, or tricyclic antidepressants [OR order stimulant laxative]

Critical Appraisal…
HTN BP stable/low ↓ number STOP STOP [at least XL] 325 mg/d only Anticonvulsant No clear seizure history Anticholinergic Confusion, constipation Oral Fe Stable Fe deficiency Oral Fe Anemia chronic disease

STOP oral Fe

…..Critical Appraisal
Parkinson Constipation Constipation Reflux Falls, agitation Decrease dose Multiple drugs Order one Dysmotility, narcotics Asymptomatic, not post-hosp Persistent with treatment Stimulant STOP H2 blockers STOP agents

UI

Side Effects
NSAIDS Tricyclics ↑ BP Constipated Switch to acetaminophen Use SSRI

Depressed

+ Stress UI

Antipsychotic

EPS

Consider duloxitine [Cymbalta] Switch to atypical

Mrs. Murdoch, 82
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Recently hospitalized, weak, tired, sleeping a lot, many near falls, new confusion and incontinence Meds: digoxin 0.25, verapamil 120 BID, ibuprofen 200 mg BID, Vitamin E 4000 IU daily, alendronate weekly, calcium carbonate 300 mg TID What is causing her symptoms?

Mr. Bede, 72
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Hospitalized with exacerbation of COPD. Meds: theophylline 400 mg TID, normal therapeutic level at last clinic visit one week ago. Three days into hospitalization has severe vomiting, agitation. What’s going on here?

Mr. Clausen, age 92…
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PMH: HTN, UI, DAT, recent pneumonia, depression, insomnia, weight loss, wandering, falls, hyponatremia, cough, edema, hypoalbuminemia, dysphagia

…Mr. Clausen, age 92…
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Aspirin 325 mg daily Atenolol 50 mg daily Hydrochlorthiazide 25 mg daily Temazepam 15 mg hs Fluoxetine 20 mg daily Lorazepam 1 mg TID Furosemide 20 mg QOD

…Mr. Clausen, age 92
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Thiazide Loop diuretic Benzodiazepines Fluoxetine

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Hyponatremic Decreased thirst Dysphagia Weight loss

Mrs. Donnigan, 83
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Recently moved to assisted living and chose medication administration assistance Digoxin 0.25, warfarin 2.5 mg, propanolol 25 mg TID, albuterol two puffs QID, St. John’s Wort QD. One week later, anorexic, nauseated, nervous

Mr. Moran, 78
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Recently hospitalized and now being seen by NP in the office. Meds: warfarin 5 mg QD, diflucan 100 mg QD, trimethoprim-sulfa [Bactrim] daily, fluoxetine [Prozac]. What are the concerns here?

Mrs. Kingsley, 72
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Noted to have recurrent documented urinary retention > 150 cc’s verapamil [Calan] 120 mg TID for HTN trimethoprim sulfa [Bactrim] for recurrent UTI’s bethanachol [Urecholine] for urinary retention

Mrs. Kingsley, 72
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NP recognized constipation as side effect of verapamil [Calan] Discontinued verapamil, started alpha blocker [Hytrin] No more residual urine, now complains of leakage of urine with cough and episodes of loosing large amounts of urine. NP orders topical estrogen cream.

Mr. Ruiz, 79
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Hydrochlorthiazide [Dyazide] 12.5 mg QD, atenolol [Tenormin] 25 mg QD, prazosin [Minipres] 1 mg QD, felopidine [Plendil] 2.5 mg QD, captopril [Capoten] 12.5 mg BID. Mr. Ruiz takes four oral agents for diabetes mellitus type 2. BP 140/90, A1C is > 8

Mrs. Johnson, 79, NF resident
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Dulcolax suppository weekly Lactulose Colace Memantine [Namenda] Donepezil [Aricept] Vitamin E

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Alendronate [Fosamax] Calcium Vitamin D

Mrs. Olson, 88
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Alendronate [Fosamax] Calcium carbonate [Tums] Albuterol [Proventil] inhaler Trazadone [Desyrel] Escitalopram oxalate [Lexapro] ACE inhibitor Calcium channel blocker Conjugated estrogen [Premarin] Fluticasone [Flovent] Levothyroxine [Synthroid]

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Diuretic Multivitamin Vitamin E Salmeterol [Serevent] Lactulose Dulcolax Zolpidem [Ambien] Acetaminophen [Tylenol] Tramadol [Ultram] Epoetin alfa [Procrit] Aspirin

Mrs. Olson, 88
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ACE inhibitor Calcium channel blocker Diuretic Salmeterol [Serevent] Fluticasone [Flovent] Levothyroxine [Synthroid] Escitalopram oxalate [Lexapro] Epoetin alfa [Procrit] Senna Tramadol [Ultram] Trazadone [Desyrel]

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Alendronate [Fosamax] Calcium carbonate [Tums] Multivitamin Vitamin E Dulcolax Acetaminophen [Tylenol] Aspirin Conjugated estrogen [Premarin] Zolpidem [Ambien] Lactulose Albuterol [Proventil] inhaler

Mr. Saunders, 82
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Admitted to hospital with acute urinary retention, confused, combative. Scheduled for urgent cystoscopy

Mrs. Larson, 93
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PMH: DAT, CHF, OP, CRF Functional Status: bedbound, UI, FI

Mrs. Larson, 93
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Donepezil [Aricept] Simvastatin [Zocor] Lisinopril [Zestril] Digoxin [Lanoxin] Metoprolol [Toprol] Alendronate [Fosamax] Calcium [Tums]

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Furosemide [Lasix] Docusate [Colace] Pantoprazole [Protonix] Vitamin E

Avoid Mishaps
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Link the problem list to medications Identify problems amenable to drugs Avoid prescribing for every symptom Re-evaluate at each visit Primary NP coordinates care Use one pharmacy

Williams, B.R. (2000). Geriatric Times, May/June Vol 1(1)

A Day in the Life of a Medication Nurse
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Licensed practical/vocational nurse (LPN/LVN)
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7 prescriptions 50 cents per medication for labor 50% will need assistance Medication Schedules
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Injections, drops, patches, creams, suppositories, inhalers Blood glucose monitoring Discourage passing meds in dining room Oral meds only in public areas

0630: insulin AC: 0700, 1100, 1600 PC: 0900, 1300, 1800 Regularly scheduled meds: 0800, 1200, 1600, 2000 PRNS

NF Tips
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Decrease doses and med passes Get to BID Eliminate noon and HS doses Avoids meds at meal times

AVOID TOO MANY
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Alternative Vague history OTCs Interactions Duration Therapeutic vs prevention Once a day..BID, TID Other prescribers

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Money Adverse effects Need Yes/No

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Drug Regimen Review Summary
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Brown Bag Review Over the Counter Drugs [OTC’s] Costs and Adherence Beer’s List Side Effects


								
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