Polypharmacy in healthcare institutepresentation.pptx

Polypharmacy

1. POLYPHARMACY By Dr Vishal Bonde JR1 MD Pharmacology TNMC & BYL Nair Hospital, Mumbai

2. POLYPHARMACY Introduction Definition Reasons Consequences Types Measure to decrease Beers criteria Conclusion References OVERVIEW It’s major public health issue. More frequently among elderly. Carries higher risk of adverse effects and/or drug - drug interactions. 2 INTRODUCTION

3. POLYPHARMACY WHO defines polypharmacy as “the administration of many drugs or excessive number of drugs at the same time.” INTRODUCTION It’s major public health issue. More frequently among elderly. Carries higher risk of adverse effects and/or drug - drug interactions. 3 OVERVIEW

4. POLYPHARMACY WHO defines as “the administration of many drugs at the same time or administration if excessive number of drugs.” INTRODUCTION More frequently among elderly. Carries higher risk of adverse effects and/or drug - drug interactions. DEFINITION 4 It’s major public health issue. Polypharmacy in India – 49%. Uttarakhand 93.1% Maharashtra 32.2% Polypharmacy In OPD patients – 57%. In IPD patients – 37%. Most common age – 70-79 yrs Bhagavathula AS, et al. Prevalence of polypharmacy, Hyperpolypharmacy and potentially inappropriate medication use in older adults in India: A systematic review and meta-analysis. Frontiers in Pharmacology. 2021;12. doi:10.3389/fphar.2021.685518

5. POLYPHARMACY DEFINITION INTRODUCTION 5 REASONS

6. POLYPHARMACY EPIDEMIOLOGY DEFINITION REASONS Polypharmacy in India – 49%. Uttarakhand 93.1% Telangana 82% Karnataka 84.6% Most common age – 70-79 yrs PIM – 28%. Polypharmacy In OPD patients – 57%. In IPD patients – 37%. 6

7. POLYPHARMACY REASONS Multiple diseases – common in elderly patients. Prescriber skills – due to improper diagnosis or lack of knowledge Self medications – generally not monitored. 7 DEFINITION

8. POLYPHARMACY REASONS Transition care – movements of patients between care settings. Reflex prescribing – when ADRs are misinterpreted as new medical condition. OTC drugs & dietary supplements. Multiple diseases – common in elderly patients. Prescriber skills – due to improper diagnosis or lack of knowledge Multiple prescribers – generally not monitored. 8 CONSEQUENCES

9. POLYPHARMACY CONSEQUENCES Duplication of therapy – because of presence of multiple medications like generic, branded, brand name version repetition is possible without awareness. ADRs – more medicines more ADRs. Drug – drug interaction 9 REASONS

10. POLYPHARMACY CONSEQUENCES Decrease adherence & compliance due to – Complex drug regimens. Incomplete explanations. Lack of knowledge about patients’ lifestyle. Cost of medicines. 10

11. POLYPHARMACY CONSEQUENCES Impaired quality of life Worsening of patient – doctor relationship. 11 TYPES

12. POLYPHARMACY TYPES CONSEQUENCES 12

13. POLYPHARMACY TYPES 13 CASE STUDY CONSEQUENCES

14. POLYPHARMACY CASE STUDY 14 TYPES A 58-year-old male underwent for esophagogastroscopy for subacute dysphagia & weight loss. His medical history includes chronic GERD, COPD, asthma, chronic neuropathy for that he is taking rabeprazole, fluticasone, benralizumab & gabapentin. A colonoscopy 4 months back for diarrhea revealed lymphocytic colitis on biopsies, for that oral budesonide 9mg / day was prescribed for 8 weeks f/b tapering down. Recent esophagogastroscopy & biopsies revealed Candida Esophagitis. Andres B, Kathi PR, Tey K. White esophagus : The result of polypharmacy. Cureus . 2023; doi:10.7759/cureus.34415 MEASURE TO DECREASE APPROPRIATE POLYPHARMACY

15. CASE STUDY 15 TYPES A 58-year-old male underwent for esophagogastroscopy for subacute dysphagia & weight loss. His medical history includes chronic GERD, COPD, asthma, chronic neuropathy for that he is taking rabeprazole, fluticasone, benralizumab & gabapentin. A colonoscopy 4 months back for diarrhea revealed lymphocytic colitis on biopsies, for that oral budesonide 9mg / day was prescribed for 8 weeks f/b tapering down. Recent esophagogastroscopy & biopsies revealed Candida Esophagitis. Andres B, Kathi PR, Tey K. White esophagus : The result of polypharmacy. Cureus . 2023; doi:10.7759/cureus.34415 MEASURE TO DECREASE APPROPRIATE POLYPHARMACY

16. POLYPHARMACY EXAMPLE 16 TYPES 4 months back, 40 years old Mr. X, was diagnosed with hypertension. He is a known case of DM, osteoarthritis. His medication regimen includes drugs like Metformin, glimepiride, enalapril, amlodipine, celecoxib. Recently, he visited his physician with complaint of dry cough. Physician added dextromethorphan to his prescription. MEASURE TO DECREASE INAPPROPRIATE POLYPHARMACY

17. EXAMPLE 17 TYPES 4 months back, 40 years old Mr. X, was diagnosed with hypertension. He is a known case of DM, osteoarthritis. His medication regimen includes drugs like Metformin, glimepiride, enalapril, amlodipine, celecoxib. Recently, he visited his physician with complaint of dry cough. Physician added dextromethorphan to his prescription. MEASURE TO DECREASE INAPPROPRIATE POLYPHARMACY

18. POLYPHARMACY MEASURE TO DECREASE BEERS CRITERIA by Mark H. Beers – List & describes potentially inappropriate medications. Mark H. Beers (1954-2009) Impaired quality of life. Worsening of patient – doctor relationship. START (Screening Tool to Alert doctors to Right Treatment) – evidence based prescribing indicators 18 BEERS CRITERIA EXAMPLE

19. POLYPHARMACY BEERS CRITERIA 19 MEASURE TO DECREASE 1) For potentially inappropriate medication in older adults 2) For potentially inappropriate medication in older adults due to drug –disease interaction

20. POLYPHARMACY BEERS CRITERIA 20 MEASURE TO DECREASE 2) For potentially inappropriate medication in older adults due to drug – disease interaction

21. POLYPHARMACY BEERS CRITERIA 21 MEASURE TO DECREASE 3) For potentially clinically important drug – drug interactions that should avoided in older adults

22. POLYPHARMACY BEERS CRITERIA Criteria 22 MEASURE TO DECREASE 4) For medications that should be avoided / have their dosage reduced with varying levels of kidney function in older adults

23. POLYPHARMACY MEASURE TO DECREASE START (Screening Tool to Alert doctors to Right Treatment). Metformin with DM2 +/- metabolic syndrome (in the absence of renal impairment S. creatinine >150 𝜇mol/l OR GFR <50 ml/min/1.73m 2 ) 23

24. POLYPHARMACY MEASURE TO DECREASE Medication Appropriateness Index (MAI) – Set of criteria to use when prescribing drugs. with a score of 0 meaning the drug is appropriate and 18 representing maximal inappropriateness 24

25. POLYPHARMACY MEASURE TO DECREASE 25

26. POLYPHARMACY MEASURE TO DECREASE 26

27. POLYPHARMACY MEASURE TO DECREASE STOPP (Screening Tool of Older Person’s Prescriptions) CCBs with chronic constipation. Aspirin with no history of coronary, cerebral or peripheral arterial occlusive symptoms. 27

28. POLYPHARMACY MEASURE TO DECREASE Medstopper.com STOPP (Screening Tool of Older Person’s Prescriptions) 28

29. POLYPHARMACY MEASURE TO DECREASE Medstopper.com SAIL technique – Simple Adverse effects Indications List TIDE technique – Time Individualize Drug – drug / drug – disease interaction Educate 29

30. POLYPHARMACY MEASURE TO DECREASE SAIL technique – Simple – medications that gives once or twice a day, medications with multiple indications, use of FDC to reduce pill burden. Adverse effects – should be knowledge about adverse effects & discontinuation of that medications. Indications – medications should have an indication. List – name and dose of medications should be written in chart & shared with patients. Deprescribing Systematic process of identifying & discontinuing drug, which existing / potential harms outweigh its benefits 30

31. POLYPHARMACY MEASURE TO DECREASE Deprescribing Systematic process of identifying & discontinuing drug, which existing / potential harms outweigh its benefits 31 TIDE technique – Time – appropriate time should be given to address & discuss medication issues. Individualize – appropriate dose & medications should be selected based on PK & PD. Consider dose adjustments for patient’s renal or hepatic function. Drug – drug / drug – disease interaction – should be consider & avoided. Educate – patients & caregiver should educate regarding medications’ effects, potential adverse effects, monitoring parameters etc.

32. POLYPHARMACY MEASURE TO DECREASE Deprescribing Systematic process of identifying & discontinuing drug, which existing / potential harms outweigh its benefits SAIL technique – Simple Adverse effects Indications List TIDE technique – Time Individualize Drug – drug / drug – disease interaction Educate Steps of deprescribing 32

33. POLYPHARMACY MEASURE TO DECREASE Steps of deprescribing Role of Clinical Pharmacologist Has most appropriate wisdom in the field of therapeutics. Advice on prescribing & proper dose adjustment. Monitor patients for potential adverse effects. 33

34. POLYPHARMACY MEASURE TO DECREASE Role of Clinical Pharmacologist Has most appropriate wisdom in the field of therapeutics. Advice on prescribing & proper dose adjustment. Monitor patients for potential adverse effects. Steps of deprescribing Conclusion 34

35. POLYPHARMACY Conclusion MEASURE TO DECREASE Polypharmacy has been and always will be common among elderly population due to various co morbid conditions. Increase in the medications comes with various outcomes such as adverse effects, drug-interactions, financial burden & non-adherence etc. It is preventable problem by implementing various methods & techniques to decrease polypharmacy. 35

36. POLYPHARMACY Conclusion MEASURE TO DECREASE Polypharmacy has been and always will be common among elderly population due to various co morbid conditions. With increase in the medications comes with various outcomes such as adverse effects, drug-interactions, cost & non-adherence etc. It is preventable problem by implementing various methods & techniques to decrease polypharmacy. 36 References