CHAMP Drugs in addition to Aging Paula M. Podrazik, MD University of Chicago CHAMP: Drugs a

CHAMP Drugs in addition to Aging Paula M. Podrazik, MD University of Chicago CHAMP: Drugs a www.phwiki.com

CHAMP Drugs in addition to Aging Paula M. Podrazik, MD University of Chicago CHAMP: Drugs a

Tennis, Michelle, North Scottsdale and Paradise Valley Reporter has reference to this Academic Journal, PHwiki organized this Journal CHAMP Drugs in addition to Aging Paula M. Podrazik, MD University of Chicago CHAMP: Drugs in addition to Aging Session Objectives Content-based objectives Review key topics in Aging PharmacoRx Factors that add to risk of ADRs/ADEs polypharmacy aspects of aging pharmacology high risk/low benefit drugs Medication review Teaching method-based objectives Trigger to teach MAR Use of the CHAMP acronym to teach Use of audit tools CHAMP: Drugs in addition to Aging Overview Prevalence of drug use in the elderly Risk factors as long as ADRs Drugs & the inpatient setting Etiology of admission complaint ADRs/ ADEs while in-hospital Discharge meds Link to geriatric syndromes, e.g.,delirium, falls, UI Med Review-guidelines, no simple algorhythm

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CHAMP: Drugs in addition to Aging ADEs, Research in addition to Aging Elderly excluded from investigational trials small sample sizes Phase III trials exclusion criteria=vulnerable elder “in vivo” no look at drugs in combo Under-reporting of drug safety problems Schmucker DL, et al:J Clin Pharmacol 1999;39:1103-8 Avorn J: Br Med J 1997;315:1033-1034 CHAMP: Drugs in addition to Aging ADR/ADE-defined Adverse Drug Reaction (ADR) any undesirable or noxious drug effect at st in addition to ard drug treatment doses WHO;1996 Technical Report Series No. 425 Adverse Drug Event (ADE) ADRs + errors in drug administration CHAMP: Drugs in addition to Aging ADRs/ADEs ADRs Amplified drug effects Drug-nutrient interaction Drug-drug interaction Drug-disease interaction Side-effects not therapeutic failures not ADWEs

CHAMP: Drugs in addition to Aging ADR Risk Factors Carbonin P, et al JAGS 1991;39:1093-1099 CHAMP: Drugs in addition to Aging ADR Risk Factors prior ADRs high risk drugs of drugs medical problems aging pharm fragmented care Adverse Drug Reaction CHAMP: Drugs in addition to Aging ADEs in addition to Hospitalization Recent inhospital studies look at ADEs How big a problem 4th-6th leading cause of hospital death (serious ADRs 6.2%, fatal ADRs 0.32%) Increased length of stay Increased cost Lazarou J, et al JAMA 1998; 280(20):1741-44 Classen D, et al JAMA 1997; 277(4): 301-6

CHAMP: Drugs in addition to Aging ADEs in addition to Hospital Cost Preventable error Preventable cost 4031 adult admissions to 700-bed Harvard teaching hospitals Look at ADEs & preventable ADEs ~$ 5.6 million/year as long as all ADE ~$ 2.8 million/year in preventable ADEs Bates DW, et al JAMA 1997;277: 307-311 CHAMP: Drugs in addition to Aging Hospital ADEs-Preventable Error 247 ADEs, 70 deemed preventable Presentation CNS complications 21% preventable ADEs-delirium most common Cardiovascular complications 19% of preventable ADEs-hypotension most common Culprit drugs Combined analgesics, sedatives in addition to antipsychotics 46% of preventable ADEs Bates DW, et al JAMA 1997;277:307-311 CHAMP: Drugs in addition to Aging Teaching & Tools What to teach How to teach Teach on a topic-polypharmacy, aspects of aging pharmacology, high risk/low benefit drugs Teach about a drug-high risk/low benefit drug or class of drugs Teach medication review Use MAR as teaching trigger Use of audits

CHAMP: Drugs in addition to Aging MAR as the Teaching Trigger An acronym as long as teaching that captures the factors that put the elderly at risk as long as ADRs in addition to more C-Cost, compliance H-Hazardous interactions A-Aging pharmacology M-Medications to avoid P-Polypharmacy CHAMP: Drugs in addition to Aging Case 1 85 y/o with h/o DM, CHF, lumbar spinal stenosis admitted with increasing confusion in addition to falls. Lives alone, daughter involved. Daughter notes patient h/o anxiety but c/o insomnia in addition to phoning her continuously throughout the night as long as the past 3 nights. Brought to U of C ER by daughter after a witnessed fall. New patient to the U of C system. Admitted at 3AM to telemetry. On exam, alternately agitated in addition to somnolent, oriented to person only. VS: T99, P54, RR20, BP110/50 lying supine wt. 100lbs. 5’1” Cor: RRR, +S3 Lungs: dry crackles in bases Abd: soft, nontender, nondistended, firm stool felt throughout colon ER data:CT head neg., dirty urine, CXR with cor, KUB FOS, BUN 48/CR 2.7, glc= 74, K+ hemolyzed at 6.3 F/U pending,INR=3.0, EKG SB-rate 58, no peaked t waves. Given dose IV antibiotics in ER. CHAMP: Drugs in addition to Aging Med List on Admission Medication list Lisinopril 40 mg qAM Digoxin 0.25 mg qAM Lasix 40 mg po qAM Aldactone 25 mg po qAM Glucotrol XL 10 mg BID Amitryptiline 25mg qHS Amiodarone 200 mg BID Coumadin 5 mg qHS Paxil 10 mg qHS Ativan 1 mg BID prn anxiety Prns Lomotil prn diarrhea Unisom prn sleep Tylenol 3 prn LBP

CHAMP: Drugs in addition to Aging MAR as the Teaching Trigger C-Cost, Compliance H-Hazardous Interactions A-Aging Pharmacology M-Medications to Avoid P-Polypharmacy CHAMP: Drugs in addition to Aging Polypharmacy Hazzard, Principles of Geriatric Medicine in addition to Gerontology CHAMP: Drugs in addition to Aging Polypharmacy Summary Polypharmacy Administration of more drugs than clinically indicated Risk of ADR greatly on >5 meds ~50 % of elderly take one or more unnecessary meds at hospital D/C, elderly take greatest meds Schmader K, et al JAGS 1994;42:1241-47 Lipton HL, et al Med Care 1992;30:646-58

CHAMP: Drugs in addition to Aging Cost of Polypharmacy risk geri syndromes Polypharmacy health care costs risk inappropriate Rx risk drug interactions functional status CHAMP: Drugs in addition to Aging MAR as the Teaching Trigger C-Cost, Compliance H-Hazardous Interactions A-Aging Pharmacology M-Medications to Avoid P-Polypharmacy CHAMP: Drugs in addition to Aging Drugs to Avoid High risk/low benefit drugs meds/classes of meds that should generally be avoided in > 65 ineffective high risk w/safer alternative available meds to avoid due to specific medical condition Consensus expert panel Fick DM Arch Intern Med 2003;163:2716-2724 Beers MH Arch Intern Med 1997;157:1531-1536

CHAMP: Drugs in addition to Aging Med List on Admission Medication list Lisinopril 40 mg qAM Digoxin 0.25 mg qAM Lasix 40 mg po qAM Aldactone 25 mg po qAM Glucotrol XL 10 mg BID Amitryptiline 25mg qHS Amiodarone 200 mg BID Coumadin 5 mg qHS Paxil 10 mg qHS Ativan 1 mg BID prn anxiety Prns Lomotil prn diarrhea Unisom prn sleep Tylenol 3 prn LBP CHAMP: Drugs in addition to Aging Amiodarone use MAR 1 On Beers avoid list Indications Dosing Side-effects Other treatment options CHAMP: Drugs in addition to Aging MAR as the Teaching Trigger C-Cost, Compliance H-Hazardous Interactions A-Aging Pharmacology M-Medications to Avoid P-Polypharmacy

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CHAMP: Drugs in addition to Aging Drug Pharmacology Pharmacokinetics drug absorption, distribution, trans as long as mation, elimination Pharmacodynamics intensity of the drug response at its receptor site CHAMP: Drugs in addition to Aging Drug Distribution with Aging body fat to age 60-70 antipsychotics, TCAs in lean body mass in addition to fat after 70 digoxin conc. protein-binding can effect Vd no sign. in total protein binding CHAMP: Drugs in addition to Aging Hepatic Biotrans as long as mation Age- related decline Reduction in liver blood flow Reduction in hepatic oxidation: CYP450 No age-related changes Hepatic acetylation Hepatic conjugation

CHAMP: Drugs in addition to Aging Cytochrome P450 Systems CYP3A Metabolizes >60% of prescribed drugs including: Calcium channel blockers, certain beta-blockers, most “statins”, warfarin, amiodarone CYP2D6 Metabolizes: metoprolol, propranolol, tramadol, codeine,oxycodone,TCAs, SSRIs CHAMP: Drugs in addition to Aging Cytochrome P450 Inhibitors CYP3A Inhibitors Amiodarone, cimetadine, cyclosporin, erythromycin, itra-/ketoconazole,grapefruit juice CYP2D6 Inhibitors Cimetidine, SSRIs, quinidine CHAMP: Drugs in addition to Aging Renal Clearance in addition to Aging ~ age 40, renal func. declines 1% per year Normal serum Cr normal GFR Estimate using Cockcroft-Gault equation Creatinine clearance = (140-age) Wt (kg) ( 0.85 in women) 72 serum Cr Modified MDRD GFR estimate= 186x(Cr)-1.154x (Age)-0.203x (0.742, if female) x (1.21, if African American)

CHAMP: Drugs in addition to Aging Bibliography 12. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean R, Beers MH. Updating the Beers Criteria as long as potentially inappropriate medication use in older adults. Arch Int Med 2003; 163: 2716-24. 13. Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M, Benser M, Edmondson AC, Bates DW. Incidence in addition to preventability of adverse drug events in nursing homes. Am J Med 2000; 109: 87-94. 14. Hanlon JT, et al: A method as long as assssing drug therapy appropriateness. J Clin Epidemiol 1992; 45: 1045-51. 15. Hanlon JT, Artz MB, Pieper CF, et al. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother 2004; 38: 9-14. 16. Inouye SK, et al: Precipitating factors as long as delirium in hospitalized elderly persons: predictive model in addition to interrelationship with baseline vulnerability. JAMA 1996;275: 852-57. 17. Kroenke K: Polypharmacy : causes, consequences, in addition to cure. Am J Med 1985;79:149-52. CHAMP: Drugs in addition to Aging Bibliography 18. Kaiser Family Foundation. Views of the new Medicare drug law: a survey of people on Medicare. August 2004. 19. Lazarou J, et al: Incidence of adverse drug reactions inhospitalized patients: a meta-analysis of prospective studies. JAMA 1998; 279: 1200-5. 20. Leape L: Reporting of adverse events. NEJM 2002;347: 1633-38. 21. Lipton HL, et al: The impact of clinical pharmacists’ consultations on physicians geriatric drug prescribing: a r in addition to omized controlled trial. Med Care 1992; 30: 646-58. 22. Ryan AA. Medication compliance in addition to older people: a review of the literature. Int’l J Nursing Studies 1999; 36: 153-162. 23. Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, Lewis IK, L in addition to sman PB, Cohen HJ. A summated score as long as the medication appropriateness index: development in addition to assessment of clinimetric properties including content validity. J Clin Epidemiol 1994; 47(8):891-896. 24. Schmader K, et al: Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994; 42: 1241-47. CHAMP: Drugs in addition to Aging Bibliography 25. Stuck AE, Beers MH, Steiner A, Aronow HU, Rubenstein LZ, Beck JC. Inappropriate medication use in community-residing older persons. Arch Intern Med 1994; 154: 2195-2200. 26. Van Eijken M, Tsang S, Wensing M, de Smet PAGM, Grol RPTM. Interventions to improve medication compliance in older patients living in the community: a systematic review of the literature. Drugs & Aging 2003; 20: 229-240. 27. Illinois Department of Public Aid website, ©2004.

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