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Polypharmacy
- 1. POLYPHARMACY PRESENTED BY- Dr. AakankshaPriya JR-1 Department of Pharmacology AIIMS, Patna
- 2. OVERVIEW Introduction Classification of polypharmacy Reasonsfor polypharmacy Outcomes of polypharmacy Economic impact of polypharmacy Measures to control polypharmacy Conclusion Summary.
- 3. INTRODUCTION The WHO haspredicted that the number of older people (conventionally defined as ≥65 years) worldwide will reach 1.5 billion by 2050. This population growth poses significant challenges for healthcare systems, as older people use a disproportionate amount of healthcare resources (eg, medications).
- 4. DEFINITION According to WorldHealth organization(WHO), Polypharmacy is described as the routine use of five or more medications( that includes Over-the-counter, prescription and/or traditional and complementary medications used by a patients).
- 5. EPIDEMIOLOGY Most common inGeriatric patients. Prevalence(India) = 33%. Prevalence(state wise)- Uttarakhand = 93.14% Karnataka = 84.6% Andaman and Nicobar Islands = 2%. ( Priya S, Gupta NL et al.)
- 6. CLASSIFICATION OF POLYPHARMACY-I •Rational use of drugs Appropriate Polypharmacy/Therapeutic Polypharmacy • Irrational use of drugs Inappropriate Polypharmacy/Contra-Therapeutic Polypharmacy • False reporting of consumption of medication. Pseudo Polypharmacy
- 7. CLASSIFICATION OF POLYPHARMACY-II inDepressionSame- class Polypharmacy • Two selective serotonin reuptake inhibitors eg- Fluoxetine plus Paroxetine. In bipolar disorderMulti-class Polypharmacy • Lithium along with an atypical antipsychotics- eg- Fluoxetine/ olanzepine. In Depression associated InsomniaAdjunctive Polypharmacy • Use of Trazadone along with Bupropion/Fluoxetine.
- 8. CONT…. In Psychosis Augmentation • Additionof lower dose of Haloperidol in patients with partial response to Resperidone. Use of Prescription medications along with OTC medications and alternative medical therapies. Total Polypharmacy
- 9. REASONS FOR POLYPHARMACY Appropriatereasons Inappropriate reasons Elderly/Patients with multiple co-morbid medical conditions. Self medications Hospitalization Doctors change from one medication to other within the same class, but patients does not stop taking the previous medication Medical conditions which requires multiple drug regimen(eg TB) Doctors also may have put the patients on brand name and write the next prescription for a generic drug. The patients continues to take both without realizing they are the same medication.
- 10. HIGH RISK POPULATION 1.Age= ≥85 yrs. 2. Hemodynamically unstable patients 3. Low body weight 4. Females 5. Six or more chronic disease states 6. History of adverse drug reactions.
- 11. OUTCOME OF POLYPHARMACY 1.Positive Outcome 2. Negative Outcome.
- 12. POSITIVE OUTCOME POLYPHARMACY SYNERGISTIC COMBINATION Eg- Hypertension ADDITIONALDRUG IMPROVES OUTCOME Eg-in myocardial infraction SUPPLEMENTAL DRUG IMPROVES ADR OF THE INITIAL DRUG Eg- anticholinergic drugs added to prevent extrapyramidal symptoms POSITIVE OUTCOME
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- 15. ECONOMIC IMPACT OFPOLYPHARMACY Increase in medication expenditure. Higher expenditure on the hospital admission.
- 16. CONTROLLING MEASURES Role ofPhysicians Role of consumers Role of pharmacist Steps taken by WHO
- 17. ROLE OF PHYSICIAN Inquireabout patient’s medications history Rational Prescribing of drugs Counseling of the patient(consumption, follow up and ADRs)
- 18. ROLE OF CONSUMERS 1.One should not be afraid to ask questions(most imp.) 2. The patients should know the name of the medications, its indications, its ADRS, and drug interactions 3. Brown-Bag it:- patient should take all the prescribed drugs, OTC drugs before leaving the hospital and should ensure regular follow up.
- 19. ROLE OF PHARMACIST 1.Hospital pharmacist- review the complete and accurate list of patients medications. 2. Long- term care pharmacist – to evaluate drug therapy regimens in predominantly elderly patients. 3. Community pharmacist- preventing the dispensing of unnecessary, inappropriate, and side effects-prone medication.
- 20. KEY STEPS FORENSURING MEDICATION SAFETY (WHO)
- 21. WHO PROGRAMMES ON POLYPHARMACY 1.OPERAM 2. PRIME- eDS 3. SIMPATHY
- 22. BEER’S CRITERIA Originally framedby- Dr.Mark Beers(Geriatrician) First published by American Geriatrics Society in 1991. Last updated in 2019. It contains list of potentially inappropriate medications for use in older age group(>65yrs) to decrease ADRs. Intended to be use in all ambulatory, acute, and institutionalized settings of care.
- 23. American Geriatrics SocietyBeers Criteria® for Potentially Inappropriate Medications: Drugs To Be Used With Caution in Older Adultsa Drugs Rationale Recommendation Aspirin for primary prevention of cardiovascular disease and colorectal cancer Risk of major bleeding from aspirin increases markedly in older age. Use with caution in adults ≥70 years Dabigatran Rivaroxaban Increased risk of gastrointestinal bleeding compared with warfarin. Use with caution for treatment of VTE or atrial fibrillation in adults ≥75 years Prasugrel Increased risk of bleeding in older adults; benefit in highest-risk older adults (eg, those with prior myocardial infarction or diabetes mellitus). Use with caution in adults ≥75 years
- 24. CONT…. DRUGS RATIONALE RECOMMENDTION Antipsychotics Carbamazepine Diuretics Mirtazapine Oxcarbazepine SNRIs SSRIs TCAs Tramadol Mayexacerbate or cause SIADH or hyponatremia; monitor sodium level closely Use with caution Trimethoprim-sulfamethoxazole Increased risk of hyperkalemia when used concurrently with an ACEI or ARB in presence of decreased creatinine clearance Use with caution in patients on ACEI or ARB and decreased creatinine Clearance.
- 25. OTHER CRITERIAS STOPP- STARTCRITERIA DEPRESCRIBING GUIDELINES AND ALORITHMS.
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- 27. CONCLUSION Polypharmacy has beenand always will be common among the elderly population due to the need to treat develops as patient ages. Unfortunately with this increase in the use of multiple medications comes with an increased risk for negative health outcomes such as higher-healthcare cost, ADEs, drug-interactions, medication non- adherence etc. Moreover, it is a preventable problem by implementing the methods to decrease polypharmacy.
- 28. SUMMARY Prevention is betterthan cure.
- 30. 1. Determine allmedication being taken 2. Identify indication for all medications 3. Identify any potential ADE for all the medications 4. Recommend elimination of all the medication without any therapeutic benefits. 5. Recommend substituting medication with lesser side effects. 6. When possible, select agents with less frequently dosing schedule. 7. Recommend starting with a lower dose and increase it slowly 8. Keep drug regimen as simple as possible 9. Review all medication profiles routinely 10. Encourage patients to follow-up routinely.