Polypharmacy and the Pain of Arthritis Management. Objectives

Transcription

1 Polypharmacy and the Pain of Arthritis Management Johnanna Hernandez, PhD, RN, FNP-BC Objectives Discuss effective persistent arthritis pain management in older adults. Describe methods of assessing pain in older adults. Evaluate pharmacological strategies for managing pain in older adults. Identify common drug-to-drug interactions involved with pain medications. Discuss key education points for patients and families. Implications Depression Social withdrawal Sleep disturbances Impaired mobility Decreased engagement Increased health care use Falls/gait disturbances Cognitive decline Deconditioning Malnutrition Slowed rehabilitation 1

2 Efforts to Improve 2001 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2009 American Geriatric Society Panel on the Pharmacological Management of Persistent Pain in Older Persons American Pain Society American Society for Pain Management in Nursing Evaluating Pain Defined as a complex, multidimensional subjective experience with sensory, cognitive, and emotional dimensions Pain is whatever the experiencing person says it is, existing whenever he says it does (McCaffery, 1968) Biases, misconceptions, misunderstandings Challenges to Management Persistent pain underdetected and poorly managed Individual based Normal part of aging Being labeled Fear of disease progression Fear of addiction Cost Pain is not important 2

3 Provider based Normal part of aging Fear of addiction Fear of adverse effects Cognitive status Own biases, beliefs, and behaviors Self-Report Pain Gold standard for pain assessment Ask about pain in regular and frequent intervals Numerical Rating Scale (NRS) Verbal Descriptor Scale Faces Pain Scale (FPS) Dementia and Pain Assessment Hierarchical pain assessment Attempt to obtain self-report of pain Search for an underlying cause of pain Observe for pain behaviors Seek input from family and caregivers 3

4 Observational Measures Guarded movement Bracing Rubbing the affected area Grimacing Painful noises or words Restlessness Elevated vital signs Pain Behavior Scales Checklist of Nonverbal Pain Indicators (CNPI) Pain Assessment in Advanced Dementia (PAINAD) Pain Assessment Checklist for Seniors with Severe Dementia (PACSLAC) Managing Pain Goal is to maximize function and quality of life by minimizing pain whenever possible Multimodal approach Pharmacological and nonpharmacologial Consider severity of pain, cognitive status, cost, physical state 4

5 Guidelines AGS Panel of the Pharmacological Management of Persistent Pain in Older Adults American Pain Society Pharmacological Pain Treatment Mutual decision-making Risks vs benfits Frequent review of drug therapy Clear goals Guiding Principles Initiated immediately upon detection of pain Regularly scheduled Multiple modalities for evaluation (verbal, behavioral, functional) and titrate accordingly Individually based 5

6 Special Considerations Confounding factors Comorbidities Polypharmacy Drug-to-drug interactions Age-related physiological changes Increased risk of side effects Start low and go slow Oral route 1 st choice Preventive approach Nonopiod Medications Acetaminophen considered drug of choice for mild-to-moderate pain Total daily dose not exceed 4 g/day or 3g/day in frail elders Reduce max dose by 50%-75% if impaired hepatic metabolism, renal disease, or history of alcholol abuse Potential risk for hepatic toxicity Nonopiod Medications Nonsteroidal anti-inflammatory drugs (NSAIDS) Not recommended for use in persons olderder than age 75 years Nonselective NSAIDS (ibuprofen, naproxen) Cyclooxygenase (COX)-2 selective inhibitors use cautiously Cardiovascular and GI side effects All age 65 and older at moderate risk for GI side effects and should receive PPI 6

7 PPIs Used longer-term to prevent NSAID induced ulcers Appropriate to start in patients taking NSAIDs with a risk ractor for GI bleeding such as older age and concomitant use of a corticosteroid, anticoagulant, or antiplatement Prevent recurrent of GI ulcers But wait.. Risks that may be elevated for some older people when PPIs are used regularly and long term include Fractures Enteric infection Community-acquired pneumonia. Other Medications Tramadol Narcotics Glucosamine 1500 mg/day may retard the loss of articular cartilage with some relief of pain May increase blood glucose Topical capsaicin Can be locally irritating Intra-articular injection 7

8 Nonpharmacological Treatment Relaxation (deep breathing, medication, imagery, music) Activity modification Massage Heat of cold application Psychological pain relief strategies AGS Exercise Prescriptions Weight reduction Water aerobics Use of a cane Beers Criteria Drugs and Categories of Drugs Why these drugs may be inappropriate for older adults Recommendations Non COX-selective Non-Steroidal Anti-inflammatory Drugs (NSAIDs), oral Aspirin at doses higher than 325 milligrams per day Diclofenac Diflunisal Etodolac Fenoprofen Ibuprofen Ketoprofen Meclofenamate Mefenamic acid Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac Tolmetin These medications increase the chance of stomach and intestinal bleeding in adults 75 or older, and adults 65 and older taking certain other medications (like prednisone warfarin, and clopidogrel) and medicines to prevent stroke. Taking a powerful stomach medication like a protonpump inhibitor (omeprazole) or misoprostol at the same time as these drugs lowers but doesn t eliminate these risks Do not use these medications regularly unless there are no other effective alternatives and they are prescribed along with a protonpump inhibitor or misoprostol. Beers Criteria Drugs and Categories of Drugs Why these drugs may be inappropriate for older adults Recommendations Indomethacin Ketorolac These drugs are NSAIDs Avoid that are even more likely to increase the chance of stomach and intestinal bleeding and ulcers or to cause other harmful effects. Pentazocine This pain reliever can cause confusion, hallucinations and other side effects. Safer medications are available. Avoid 8

9 Beers Criteria Drugs and Categories of Drugs Why these drugs may be inappropriate for older adults Recommendations Skeletal muscle relaxants Carisoprodol Chlorzoxazone Cyclobenzaprine Metaxalone Methocarbamol Orphenadrine Most muscle relaxants have questionable effectiveness and can cause side effects such as sleepiness and increased risks of bone fractures in older people. Avoid Beers Criteria Disease or Syndrome Drug(s) Rationale Recommendation Heart failure Nonsteroidal antinflammatory drugs (NSAIDs) and COX-2 inhibitors (see above list for examples) These drugs may increase the chance of fluid retention, and contribute to heart failure. Avoid Delirium H2-receptor antagonist These medications Avoid can cause or worsen delirium in older people. Avoid these drugs in older adults with or at high risk of delirium. Beers Criteria Disease or Syndrome Drug(s) Rationale Recommendation Dementia and cognitive/mental impairment H2-receptor antagonists Avoid these drugs in adults with cognitive or thinking problems because these medications may make this worse. Avoid Repeated stomach or intestinal ulcers Aspirin at doses higher than 325 milligrams per day Non COX-2 selective NSAIDs These drugs may make ulcers worse and increase the chance of new ulcers Avoid these drugs unless other medications are not effective and the patient can take an accompanying medication that can help prevent ulcers such as a proton-pump inhibitor or misoprostol. 9

10 Beers Criteria Disease or Syndrome Poor kidney function Drug(s) Rationale Recommendation Nonsteroidal antiinflammatory drugs Triamterene These drugs may increase risks of potentially serious kidney damage. Avoid Rheumatoid Arthritis (RA) Symmetric polyarticular inflammatory arthritis with a characteristic pattern of joint involvement. New-onset RA can be seen in older adults Symptoms Inflammatory joint symptoms Joints feel better with use and worse with rest Joints stiffen with inactivity Morning stiffness is a prominent complaint It takes at least 1 hour for the joints to loosen up Worse time of the day is generally several hours before and after awakening Pain, stiffness, and swelling in a fairly symmetric pattern usually in PIP, MCP, and MTPs May have symptoms of carpal tunnel syndrome 10

11 Physical Exam Warmth, synovial thickening, joint tenderness, loss of hand grip strength, pain with joint motion, and loss of range of motion Rheumatoid nodules RF seen in 80% of patients False-positive RF is high in elderly Evidence of acute phase resonse ( sed rate, CRP, serum albumin) Synovial biopsy (cloudy-yellow, WBC) RA Treatment Prednisone short-term control of symptoms NSAIDs for short relief of pain and inflammation Disease-modifying antirheumatic drugs (DMARDs) Methotrexate DMARD of choice Once a week, orally or injection Immunosuppression secondary to reducing activity of B and T lymphocytes Adverse effects: alopecia, mucositis, diarrhea, cytopenias, hepatic transaminases, opportunistic infections, pneumonitis Folic acid 1 mg/day (at least 5 mg/week) to reduce GI and hepatic toxicity 11

12 Methotrexate Periodic liver and kidney tests CBC and platelets Contraindicated in pregnancy, male and female precautions 767 drug interactions, 188 major Drug Interactions 767 drug interactions, 188 major Caffeine can reduce effectiveness Avoid meds that affect liver, alcohol References AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2013). The AGS Foundation for Healthy Aging. American Geriatric Society (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57(8), Boltz, M., Capezuit, E., Fulmer, T., & Zwicker, D. (2012). Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: Springer. Brunton, L.L., Chabner, B.A., & Knollman, B.C. (2011). Goodman & Gilman s The Pharmacological Basis of Therapuetics, 12 th edition. New York: McGraw Hill. Kane, R.L., Ouslander, J.G., Abrass, I.B., & Resnick, B. (2009). Essentials of Clinical Geriatrics, 6 th edition. New York: McGraw Hill. Srivastave, M., & Deal, C. (2004) Geriatric Rheumatology. Current Geriatric Diagnosis & Treatment. New York: McGraw Hill. 12