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Dangerous Drugs and How to Minimize the Dangers

Dangerous Drugs and How to Minimize the Dangers. April 17, 2014. Adapted from: American College of Physicians Internal Medicine 2012 Dangerous Drugs and How to Minimize Their Dangers Douglas S. Paauw, MD, MACP And.

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Dangerous Drugs and How to Minimize the Dangers

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  1. Dangerous Drugs and How to Minimize the Dangers April 17, 2014

  2. Adapted from: American College of Physicians Internal Medicine 2012 Dangerous Drugs and How to Minimize Their Dangers Douglas S. Paauw, MD, MACP And...

  3. Assessing Medication Appropriateness in the Elderly: Using Beers & STOPP START Criteria Julia Bareham BSc, BSP, MSc Candidate julia@rxfiles.ca RxFiles Academic Detailing Program

  4. Disclosures • Dr. Anthony Weaver has no relationships to disclose.

  5. Objectives • Review some of the most dangerous drugs used in general medicine practice (emphasizing drug-drug interactions). • Discuss ways to prescribe these drugs safely. • Beers Criteria • STOPP Criteria • Most dangerous drug • CYP 3A4 Interactions • Evaluate the interactions that make certain drugs dangerous.

  6. Over 2 million serious ADRs annually • 100,000 deaths annually • Fourth leading cause of death • Ambulatory patient’s ADR rate is unknown Institute of Medicine. To err is human: building a safer health system. Washington, D.C.: National Academy Press; 2000. 2Lazarou J, Pomeranz B, Corey PN. Incidence of adverse drug reactions in hospitalized patients: A meta-analysis of prospective studies. JAMA 1998;279:1200–1205. 3Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000;109(2):87–94.

  7. Medication Related Problems • Seniors = 12.9% of U.S. population, but 34% of total prescriptions. • > 65 • 40% take 5-9 medications per year • 18% take 10 or more • ADRs among the top five threats to seniors’ health. • 28% of hospitalizations among seniors due to ADRs. • 32,000 seniors suffer hip fractures/yr due to falls caused by medication-related problems. American Society of Consultant Pharmacists

  8. Medication Related Problems • Drug related admissions for aged 65-84 increased by 96% from 1997 to 2008 • Half of ADR hospitalizations occur in > 80 yo • Rapidly growing senior population will magnify the problem

  9. Shepherd G et al. Ann Pharmacother 2012;46:169-175

  10. Figure 2. Adverse drug reaction death rates by state (1999–2006). Shepherd G et al. Ann Pharmacother 2012;46:169-175

  11. Medication Related Problems Estimated Annual Cost • $76.6 billion among ambulatory population • $20 billion in acute-care facilities • $7.6 billion in nursing facilities • Total annual direct medical cost in the US: $104.2 billion American Society of Consultant Pharmacists

  12. AGS UPDATED 2012 BEERS CRITERIA FOR POTENTIALLY INAPPROPRIATE MEDICATION USE IN OLDER ADULTS

  13. Mark H Beers, MD 1954-2009 • MD, Univ of Vermont • First med student to do a geriatrics elective at Harvard‘s Division on Aging • Geriatric Fellowship, Harvard • Faculty, UCLA/RAND • Co-editor, Merck Manual of Geriatrics • Editor in Chief, Merck Manuals “A ballet-dancing opera critic who hiked the Alps and took up rowing after diabetes cost him his legs”

  14. Original Purpose 1991 Original Beers Criteria • Evaluate inappropriate Rx used in NH residents in “common” situations, but under “certain circumstances” might be appropriate • Clinical research on use of Potentially Inappropriate medications (PIMs) • QA/QI • Education

  15. Not included in Beer’s List • Drugs with risks not unique to elderly • Purpose is for PIMs specific to elderly • Drug-drug interactions • Not unique to elderly • List of alternatives • Too complex, requires patient specific judgment

  16. 2012 AGS Beers Criteria - Categories

  17. FREE Beers Criteria Apps

  18. Print off the Pocket Card www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf Or, search “Beers pocket card” Open access, available for free.

  19. Drugs to Avoid (except if….) • Table 1 in the pocket guide

  20. Table 1. Drugs to Avoid (except if…)

  21. Table 1. Drugs to Avoid (except if…)

  22. Table 1. Drugs to Avoid (except if…)

  23. Use of Caveats • “Z” drugs for sleep: avoid chronic use • Testosterone: avoid unless indicated for moderate to severe hypogonadism • Topical vaginal estrogen: acceptable low dose use for specific conditions • Spironolactone: avoid >25 mg/day in pts with heart failure or CrCl <30 • Antipsychotics: avoid unlessnonpharm treatment has failed or threat to self/others

  24. Table 2. Drug-disease/syndrome Interactions

  25. Drug-disease/syndrome Interactions • Table 2 in the pocket guide

  26. Table 3. Use with Caution

  27. Use with Caution • Table 3 in the pocket guide

  28. Non-Drug Approaches Targeting Behavior and Symptoms Educational Interventions • Dementia • “T A DA” VA Health • Tolerate, Anticipate, don’t aggravate • Resistive Behaviors • Needs Based Approach • Sleep • Cardiovascular • AGS Website Materials • Interprofessional • Use of EHR/CDSS • Target Groups • Consumers

  29. Alternate Plan Target the sickest patients, use Beers criteria

  30. JAGS July 2013; 61 (7)

  31. Introduction • PIM: potentially inappropriate medication. Pharmacological effects potentially harmful to an elderly adult • AIM: actually inappropriate medication. Risk of harm outweighs benefit • 50% of elderly adults discharged on ≥ 1 PIM • 85% of ICU survivors discharged on ≥ 1 PIM • 80% of elderly adults discharged on ≥ 1 AIM • 50% of ICU survivors discharged on ≥ 1 AIM • 50% of PIMs and 59% of AIMs rx’d in ICU

  32. Hypothesis • Opiates, sedatives, and antipsychotics are the PIMs most often AIMs in older ICU survivors • Older adults with delirium are at highest risk for discharge on PIMs and AIMs

  33. Methods • Prospective nested cohort study • Critically ill patients with respiratory failure or shock admitted to Vanderbilt ICU • Age ≥60, discharged alive • Not hospice • PIM determined by using 2003 Beers criteria • AIM by chart review by a hospitalist, geriatrician, and clinical pharmacist (2/3 wins)

  34. Drug Categories • Benzodiazepines • Non-BZD sedatives • Typical antipsychotics • Atypical antipsychotics • Opioids • Anticholinergics • Antidepressants • Drugs causing orthostasis • NSAIDs • Antiarrhythmics • Muscle relaxants • other

  35. Results:PIMs • 250 PIMs at discharge • 4 most common PIMs • Opioids • Anticholinergics • Antidepressants • Drugs causing orthostasis

  36. Results: AIMs • 90 AIMs • Three most common (36%) • Anticholinergics • Histamine blockers 61% • Promethazine 15% • Non-BZD hypnotics • Opioids

  37. PIMs transitioning to AIMs • Three least common PIM-AIM • Opioids (16% likelihood) • Antidepressants (23% likelihood) • Orthostatic drugs (10% likelihood) • Three most common PIM-AIM • Anticholinergics (55% likelihood) • Non-BZD hypnotics (67% likelihood) • Benzodiazepines (67% likelihood) • Atypical psychotics (71% likelihood) • Muscle relaxants (100% likelihood)

  38. Results • 67% of anticholinergic AIMs started in ICU • 46% of non-BZD hypnotics started in ICU • 73% of AIM opioids started in ICU • 80% of atypical antipsychotics started in ICU • 1% on atypical anti-psychotic on admission • 12% on atypical antipsychotic on discharge

  39. Discussion • 3 of the most commonly prescribed PIMs (opioids, antidepressants, and orthostatic drugs) were often appropriate for condition • Risk factors for PIMs did not predict AIMs • We should (move beyond) labeling medicines as “potentially inappropriate” • Clinicians must actively determine which PIMs can be discontinued at discharge/followup • Screening tools using [Beers] PIMs to generate alerts could lead to inappropriate discontinuation, and possibly more harmful alternatives

  40. More Discussion • Screening tools should consider positive predictive value, highest in: • Atypical antipsychotics (71%) • Non-BZD hypnotics (67%) • Benzodiazepines (67%) • Anticholinergics (55%) • Muscle relaxants (100%)

  41. STOPP Criteria Screening Tool of Older Persons’ potentially inappropriate Prescriptions 65 rules relating to the most common and the most potentially dangerous instances of inappropriate prescribing in older people O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, Barry P, O’Connor M, Kennedy J. STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age. European Geriatric Medicine. 2010 Jan 6; 1(1):45-51. Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011 Jun 13;171(11):1013-9.

  42. A. Cardiovascular System 1. Digoxin at a long-term dose > 125µg/day with impaired renal function * (increased risk of toxicity). * estimated GFR <50ml/min 2. Loop diuretics: • for dependent ankle oedema only i.e. no clinical signs of heart failure(no evidence of efficacy, compression hosiery usually more appropriate). • as first-line monotherapy for hypertension(safer, more effective alternatives available). 3. Thiazide diuretic with a history of gout(may exacerbate gout). 4. Beta-blockers: • with Chronic Obstructive Pulmonary Disease (COPD)(risk of increased bronchospasm). • in combination with verapamil(risk of symptomatic heart block). 5. Use of diltiazem or verapamil with NYHA Class III or IV heart failure(may worsen heart failure). 6. Calcium channel blockers with chronic constipation (may exacerbate constipation). 7. Dipyridamole as monotherapy for cardiovascular secondary prevention(no evidence for efficacy).

  43. 8. Aspirin: • with a past history of peptic ulcer disease without histamine H2 receptor antagonist or • Proton Pump Inhibitor(risk of bleeding). • at dose > 150mg day (increased bleeding risk, no evidence for increased efficacy). • with no history of coronary, cerebral or peripheral vascular symptoms or occlusive event (not indicated). • to treat dizziness not clearly attributable to cerebrovascular disease(not indicated). 9. Warfarin: • for first, uncomplicated deep venous thrombosis for longer than 6 months duration (no proven added benefit). • for first uncomplicated pulmonary embolus for longer than 12 months duration(no proven benefit). 10. Use of aspirin and warfarin in combination without histamine H2 receptor antagonist (except cimetidine because of interaction with warfarin) or proton pump inhibitor(high risk of gastrointestinal bleeding). 11. Aspirin, clopidogrel, dipyridamole or warfarin with concurrent bleeding disorder(high risk of bleeding).

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