intelligent polypharmacy
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Intelligent Polypharmacy
Professor Colin P Bradley
Department of General Practice
University College Cork
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Polypharmacy
No standard definition
2005 review the use of medications
that are not clinically indicated 2010 Swedish study - > 5 medicines
defined as polypharmacy and > 10
excessive polypharmacy
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Problems of polypharmacy
Increased risk & prevalence of drug-drug interactions
Increased risk & prevalence ofadverse effects
Increased risk & prevalence of non-
adherence Increased risk & prevalence of
medication errors
Increased cost
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Risk of type D* interactionsrelated to number of drugs (Astrand et.al., 2007)
* Interactions which may have serious clinical consequences
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Factors determining risk ofadverse effects of medications
Patient age, gender, ethnicity
Renal and hepatic function
Co-morbities which increase ADR riskse.g. peptic ulcer disease or heartdisease and NSAIDs
Therapeutic index of the medicine
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Factors determining risk of non-adherence
Experience of adverse effects
Experience of interactions
Complexity of medication regimen Cognitive function
Drug aversion
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Factors related to risk ofmedication error
Number of medicines prescribed
Complexity of medication regimen
SALADs sound alike, look alike drugse.g. penicillin & penicillamine
Cognitive function of doctor,
pharmacist, patient and/or carers Care setting hospital, home etc.
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Costs of polypharmacy
Costs of medicines
Costs of mechanisms to reduce error
Costs of strategies to compensate forcognitive function decline
Costs of non-adherence (waste)
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Benefits of polypharmacy =benefits of pharmacotherapy
Reduction in adverse events
prophylactic medicines
medicines to counter possible ADRs Improvement in clinical conditions
reduction in complication rates
reduction in symptoms control of disease progression
Savings to health system if usedappropriately
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What isintelligent polypharmacy?
Use of multiple medicines in patients
where the benefits of the medicinestaken still outweigh the risks intrinsicto each medicine plus the risksassociated with the combination ofmedicines.
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An example of intelligentpolypharmacy? the polypill
Proposed originally in 2003 by Wald & Law
Combination of statin, thiazide, beta-
blocker, ACE inhibitor, folic acid and aspirin Estimated to reduce risk of cardiovascular
disease by 80% in unselected population
aged over 55 yearsADR rate estimated at 8-15%
Has been trialed in India
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Other examples
H. Pylori eradication regimens
HAART for HIV infection
Multi-drug regimens for TB treatment Treatment of type 2 diabetes
usually involves metformin, other
glucose lowering drugs plus drugs forhypertension (esp ACEI) and lipidlowering drugs
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Implementing intelligentpolypharmacy in practice
Systematic review of patients on multiplemedicines
Key drugs to review drugs with narrow therapeutic index e.g.
Warfarin, digoxin etc. drugs with known detectable ADRs e.g.
Immunosuppresants watch out for the prescribing cascade (Feely)
Key conditions to review Renal disease hepatic disease
Key patient group - elderly
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SAIL and TIDE
SAIL Simple as possible
Adverse reactions look
out for them Indication to be checked
for each medicine
List all the medicines in
the notes and providecopy to the patient
TIDE Time set aside to review
medicines
Individual responsesneed to gauged
Drug-drug interactionsneed to be checked
Educate the patient abouttheir medicines
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STOPP/ START
ScreeningTool of Older
Peoplespotentially
inappropriatePrescriptions
ScreeningTool to Alert
doctors toRight (i.e.
appropriate,indicated)Treatment
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Which are the problemdrugs?
Cardiovascular
CNS and psychotropics
Gastrointestinal Respiratory
Musculoskeletal
Urogenital Endocrine
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The problem drugs -cardiovascular
Digoxin Loop diuretics Thiazide diuretics Beta-blockers Calcium channel blockersVasodilators
DipyridamoleAspirin Clopidrogrel
Warfarin
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The problem drugs - CNS
Tricyclic anti-depressants
Benzodiazepines
Neuroleptics
Phenothiazines
Anti-cholinergics
SSRIs
First generation anti-histamines
Opiates
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The problem drugs gastro-intestinal
Diphenoxylate
Loperamide
Codeine phosphate Prochlorperazine
PPIs
Anti-cholinergic anti-spasmodics
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The problem drugs respiratorysystem
Theophylline
Systemic corticosteroids
Nebulised ipratropium
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The problem drugs musculoskeletal system
NSAIDs
Corticosteroids
Colchicine
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The problem drugs urogenitalsystem
Bladder anti-muscarinics
Alpha-blockers
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The problem drugs endocrinesystem
Glibenclamide
Chlorpromamide
Oetrogens
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Other issues
Duplicate drugs same class or sametherapeutic effect
Complex regimens more than twice per day or
other special requirements for taking the drug Multiple tablets to be taken simultaneously
Look-alike tablets
Difficult formulations
Slow accumulation of medical problems (and,hence, associated medications)
Prevention v therapy
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Medications sometimes deniedinappropriately
Warfarin
Aspirin
Clopidrogrel
StatinsACE inhibitors
Beta-blockers
Beta-agonists Inhaled
corticosteroids
L-DOPA
Antidepresants
PPIs
Fibre supplements DMARDs
Bisphosphonates
Calcium and vit D Metformin
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Reducing the risk
Avoid prescribing where appropriate
Start low and go slow
Robust repeat prescribing system
Clinical pharmacy ICT solutions
Interaction alerts
Drug disease contraindication alerts
Dosage alerts including paediatric alerts
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Case 1
66 year old man with a history of
hypertension x 10yrs;
angina x 3 yrs and
osteoarthritis x 1 yr
Atenolol 100mg daily x 30
Lisinopril 5mg daily x 30
Imdur (isosorbide mononitrate) 60mg daily x 30 Nuseals aspirin 75mg x 30
Lipostat 20mg nocte x 30
Voltarol 25mg tds x 90
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Case 2
72 year old woman with 12yr history of type II diabetes,
6 yr history of hypertension
history of ankle oedema (of uncertain causeand duration).
Daonil 5mg daily x 30
Frusemide 20mg daily x 30
Tritace 10mg daily x 30 Dalmane 30mg nocte x 30
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Case 3
58 year old woman with a 9 monthhistory of hypertension
Adalat LA 20mg daily x 30
Innovace 10mg daily x 30
Moducren ii daily x 30 (combination
of hydrochlorthiazide 25mg; amiloride2.5mg and timolol maleate 10mg)
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Case 4
64 year old woman with a history of recurrent depression
was found on screening 3 years ago to haveosteoporosis
Fosamax i weekly x 8
Lexapro 10mg daily x 30
Zopiclone 7.5mg nocte x30
Nexium 20mg daily x 30 Ixprim ii prn x 100
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Case 5
62 year old man with a
4 year history of atrial fibrillation
recently presented with a first episode of gout
Digoxin .625mg od x 30
Warfarin 4mg daily (INR check 8 weekly,last reading 6 weeks ago was 2.3)
Centyl K i daily x 30 Indomethacin 50mg tds x 14 days
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Case 6
77 year old woman with 5 year history of angina,
1 year history of polymyalgia rheumatica
recently presented with indigestion
Atenolol 50mg daily x 30
Adalat 10mg three times daily x 90
GTN spray as needed x 1
Syndol i or ii as needed x 50 Prednisolone 5mg daily x 30
Gaviscon Advance 10mls as needed
Pariet 10mg daily x 30
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