American College of Physicians Internal Medicine Meeting

American College of Physicians Internal Medicine Meeting

May 07, 2016
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10 questions to ask to reduce polypharmacy, discontinue medications in elderly patients

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WASHINGTON — Reducing the glut of unnecessary medications for elderly patients can be a significant challenge, but there are 10 steps clinicians can take to successfully cut into the rampant polypharmacy many are experiencing today, according to a presentation given here at the American College of Physicians Internal Medicine Meeting.

According to Amit Shah, MD, FACP, of the Mayo Clinic Division of Community Internal Medicine, 50% of the geriatric population in the United States is on 5 or more medications, including over-the-counter drugs, with 37% on 5 or more prescription medications and 12% on 10 or more medications. He noted that polypharmacy, defined as a patient taking 4 or more medications, increases the risk for adverse drug interactions, and that most ED visits stemming from medication use are due to commonly prescribed drugs including anticoagulants, hypoglycemic agents and digoxin.

Amit A. Shah, MD

Amit A. Shah, MD, FACP

 

“I like to say that I have cured more diseases by stopping medications than by starting them,” Shah said. “Now, that’s a bit of an overstatement, but it gets people’s attention.”

To help reduce polypharmacy, and end unneeded or potentially harmful medications, in geriatric patients, Shah recommended that physicians ask themselves 10 questions. They are:

Do I know all the medications?

Obtaining accurate medication lists from patients can be difficult, even when making a house call, Shah said, noting a study finding that 70% of hospital discharge medication records had at least one error, with 30% of such errors being potentially serious.

Still, Shah said the only “foolproof” way to confirm medications is to make a house call. However, the next best alternatives are making specific orders to the home health nurse for a medication review, or arranging previsit phone calls from the pharmacy technician.

Is this medication harmful?

According to Shah, there are many published lists available on medications that are potentially harmful in elderly patients. For example, physicians should avoid long-acting sulfonylureas such as chlorpropamide, glyburide and glimepiride, and instead use glipizide.

Shah added that the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, also called the Beers List, is a guide showing “what drugs to avoid, or think twice about,” but is not a “blacklist.”

Is this drug indicated?

Avoid off-label prescribing practices. According to Shah, approximately 20% of all prescribing is off-label, a figure that grows to 40% among psychiatric drugs.

Shah noted as a cautionary tale the example of gabapentin (Neurotin), which had achieved a 90% off-label prescription rate, and was subject to the largest fine in FDA history, resulting in Pfizer/Warner-Lambert paying $430 million.

Has this drug outlived its utility?

Examples provided by Shah included proton pump inhibitors continued past hospitalization, and antidepressant medications continued indefinitely without a trial of discontinuation.

“It has happened to me, in which I will ask a patient why they are taking a medication, and they say they don’t know,” Shah said. “It was prescribed to them once when they left the hospital, and they continued to take it.”

Do the side effects outweigh the potential benefits?

Physicians should avoid prescribing drugs with “highly statistically significant, but clinically meaningless results,” Shah said.

This includes medications in which the package insert boasts “lots and lots of zeros” in the P values, but offer negligible results and introduce a variety of side effects, often while costing the patient hundreds of dollars per month, he added.

Are there any drug-drug or drug-disease interactions?

“I’m not smart enough to remember all of the drug-drug interactions,” Shah said. “There’s just too many.”

Still, physicians should beware “click through and alert fatigue,” he said, and use medication apps such as the Epocrates Multicheck or the Medscape interaction checker.

What about over-the-counter drugs, supplements or herbal medications?

Shah cautioned against supplements and herbal medications, stating, for example, that calcium supplements decrease absorption of levothyroxine, fluoroquinolone antibiotics and tetracycline antibiotics.

Is this drug being used to treat the side effects of another drug?

Prescribing medications to treat the side effects of another drug can quickly lead to “prescribing cascade,” Shah said.

He added that, in these situations, patients’ health and quality of life can be improved by cutting out medications.

Is there a nonpharmacologic approach I can try instead of a drug?

Shah recalled recommending Kegel/pelvic floor strengthening exercises, and scheduled voiding, for patients with urinary incontinence, rather than writing a prescription.

Another example would be to counsel a patient complaining of sleep problems about the normal changes in sleep with aging, as well as sleep hygiene, relaxation techniques and addressing underlying issues, which may include pain, rather than “prescribing an Ambien (zolpidem, Sanofi).”

Will my patient live long enough to gain potential benefit from the drug?

While prognostication is difficult, Shah said physicians should do their best to assess the remaining lifespan of their elderly patients, and make the often difficult decision as to whether they would see any benefit in the time they have left.

He recommended ePrognosis, an online prognosis calculator developed by the University of California in San Francisco, for when physicians are in doubt.

Disclosure: Shah reports no relevant financial disclosures.

Reference:

Shah A. Debriding the medication list: Reducing polypharmacy in the elderly. Presented at: American College of Physicians Internal Medicine Meeting; May 5 to 7, 2016; Washington, D.C.