How To Write A Medication Review

Transcription

1 Medication review for older hospialized patients Annemie Somers Ghent University Hospital, Belgium PharmD, PhD Journeé de formation CMP Studiedag MFC 25/10/13 1

2 Content Medication review: 1. Definition, process, evidence 2. How to proceed: tools 3. In practice at Ghent University Hospital: working methods practical examples 2 2

3 1. Medication review: definition, process, evidence 3 3

4 Medication review: definition From: Pharmaceutical Care Network Europe ( Generic definition: A structured, critical examination of a patient s medicines, with the objective of optimising treatment, and minimising drug related problems. (Medicines: prescribed, over the counter, complementary) The official PCNE definition: Medication review is an evaluation of patient s medicines with the aim of managing the risk and optimizing the outcome of medicine therapy by detecting, solving and preventing drug related problems. 4 4

5 Examples of drug related problems in older patients Confusion, sedation due to (combination of) psychotropics Falls due to drugs for the central nervous system, antihypertensives Electrolyte disturbances due to antihypertensive drugs Hypoglycaemia due to antihyperglycaemic drugs, insulin Bleeding due to anticoagulants, non-steroidal anti-inflammatory drugs Renal failure due to non-steroidal anti-inflammatory drugs Hyponatraemia due to antidepressants, antipsychotics 5 5

6 Medication review process Step 1: Create a patient database, and identify all the medications that the patient is taking. Step 2: Review each medication for indications, effectiveness, safety,monitoring, errors, cost, underuse, overuse, appropriateness, adverse effects, and poor compliance Step 3: Create a problemlist and set priorities Step 4: Create a plan for each identified problem Step 5: Implement the plan Step 6: Follow up on plan and make interventions as needed Consult Pharm 2008;23:

7 Medication review by clinical pharmacists An individualized assessment provided by a clinical pharmacist, during which the medication list is analyzed in a structured manner, with full access to the medical file, in order to identify drug related problems. First step: identification of all the medications that the patient is taking. Second step: the medication list is screened for drug related problems i.e. any misuse, underuse or overuse of drugs. Third step: possible solutions to the drug related problems (DRPs) are then discussed with the treating physician and, if possible, with the patient. 7 7

8 Levels of medication review Level 1 PRESCRIPTION REVIEW Level 2 TREATMENT REVIEW Review of medicines with full patient s notes Level 3 CLINICAL MEDICATION REVIEW Face-to-face review of medicines and condition Level 0 AD-HOC Unstructured, opportunistic Technical review of list of patient s medicines A guide for medication review: the agenda for patients, practitioners and managers. London: Medicines Partnership,

9 Medication review: where and which patients Setting: community pharmacy (e.g. NL) policlinics ( medication review clinics ) hospital wards nursing homes Which patients: polypharmacy (older patients) high risk pathology (e.g. renal failure) high risk drugs (e.g. immunosuppressants) high risk patients (non adherence, new drugs) 9 9

10 Medication review: evidence (1) 10 10

11 This review emphasizes that pharmacist-led medication review interventions can not be assumed to reduce hospital admissions or mortality rates in older people. These interventions may improve drug knowledge and drug adherence, but insufficient data exist to know whether the latter affects patients quality of life positively 11 11

12 Medication review: evidence (2) Strategies to reduce the risk of iatrogenic illness in complex older adults Onder G, van der Cammen T, Petrovic M, Somers A, Rajkumar C. Age Ageing 2013; 42: Available evidence on the impact of medication review, avoidance of inappropriate medications, CGA and computer-based prescribing systems is mixed and controversial. A limitation of all the described approaches is the lack of standardisation. The challenge for future research is to integrate valuable information obtained by existing instruments and methodologies in a complete and global approach targeting all potential factors involved in the onset of ADRs

13 2. Medication review: how to proceed - tools 13 13

14 Detection & prevention of DRPs in older patients Medication Assessment Tools 1) Explicit (drugs to avoid / criteria based) Beers (1991, updates 1997, 2003, 2012) McLeod (1997) ACOVE: Assessing Care of Vulnerable Elders (2001) IPET: Improved Prescribing in the Elderly Tool (2002) STOPP: Screening Tool of Older Person s Prescriptions (2008) (+ START: Screening Tool to Alert Doctors to Right Prescriptions) 2) Implicit (judgment based): MAI: Medication Appropriateness Index (1992) GMA: Geriatric Medication Algorithm (1994) Lipton s criteria (1993) Interventions Education, computerized support, pharmacist recommendations, geriatric medicine services 14 14

15 Combination of tools for medication review Explicit tools << PIM: Potentially Inappropriate Medications drugs to avoid drugs to avoid in certain circumstances drugs to use with caution in older patients drugs to start in certain circumstances appropriate use of drugs (education, continuity, monitoring, ) Implicit approach: standardized list of questions per drug individual judgment: ratings 15 15

16 Key-questions for medication review Is there an indication for each drug? Right choice of drugs? Contra-indications? Doses adapted? Adverse drug reactions? Relevant drug-drug interactions? Right route, technique and time(s) of administration & frequency Overuse (is there still an indication for each drug)? Undertreatment? Simplification of the drug scheme? 16 16

17 MAI: Medication Appropriateness Index Nr Question Weight 1 Is there an indication for the drug? 3 2 Is the medication effective for the condition? 3 3 Is the dosage correct? 2 4 Are the directions correct? 2 5 Are the directions practical? 1 6 Are there (significant) drug-drug interactions? 2 7 Are there (significant) drug-disease interactions? 2 8 Is there unnecessary duplication with other drug(s)? 1 9 Is the duration of therapy acceptable? 1 10 Is the drug the least expensive? 1 Calculation of scores: appropriate = ponderation x 0 marginally appropriate = ponderation x 0.5 inappropriate = ponderation x 1 total score per drug [0 18] Hanlon, J Clin Epidemiol 1994; 47: Example 3 x 0 = 0 3 x 0.5 = x 0.5 = 1 1 x 0 = 0 1 x 0 = 0 2 x 0 = 0 2 x 1 = 2 1 x 0 = 0 1 x 0 = 0 1 x 0.5 = 0.5 Total =

18 Practical adapted MAI Somers A, Mallet L et al. Am J Geriatr Pharmacother 2012;10:101-9 For each drug 8 questions: Nr Question Weight 1 Indication 3 2 Contra-indication 2 3 Right choice 3 4 Dose 2 5 Route of administration, time(s) of administration, frequency, administration technique 6 Adverse drug reactions 2 7 Drug-drug interactions 1 8 Duration of therapy 1 + additional question: undertreatment?

19 Case: Mrs. M Onder G et al. Age Ageing 2013; 42: Mrs. M is an 81 years old widow, living alone in her own house. She suffers from diabetes mellitus, hypertension, ischemic heart disease, glaucoma, osteoarthritis and osteoporosis. Her weight is 46 kg and she is 160 cm tall. Because of osteoarthritis she reports slowness and reduced level of physical activity. She is currently on the following drugs: Atenolol 50 mg/day, Perindopril 5 mg/day, Pantoprazole 20 mg/day, Metformin 1000 mg/day, Hydrochlorothiazide 12.5 mg/day, Timolol eye drops (0.5%, twice daily in both eyes), ASA 100 mg/day, Diazepam 5 mg/day. Her blood pressure is 152/88 mmhg and her last HbA1c was 8.2%

20 Mrs. M: Medication review Potential DRPs Perindopril, hydrochlorothiazide, and metformin: are doses adjusted for renal function? Metformine: the HbA1C-level is not satisfactory and attempts should be made to improve glucose control, but with due regard to avoiding hypoglycaemic episodes. Diazepam: inappropriate in older adults because of increased risk of falls Calcium/vitamin D and bisphosphonate may be necessary given the diagnosis of osteoporosis Pantoprazole: no clear indication Atenolol: not the best choice for the treatment of hypertension Timolol: combined use of timolol and atenolol can increase the risk of symptomatic bradycardia and falls This list is then discussed with the treating physician and a plan for implementation and evaluation is created 20 20

21 3. Medication review in practice 21 21

22 Step 1: medication reconciliation Funded project, emergency department, half-time Focus on elderly patients, polypharmacy, admission Drug history by trained pharmacy technicians Electronic registration Facilitates in-hospital prescribing (incl: automatic substitution) Training for nurses: how to perform a drug history? Possible shift towards in-take (policlinic, admission unit) 22 22

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24 MEMORY AID for nurses Record for each drug: Starting date (HM or specific date if recently started) Drug name (written out) Dose Quantity per administration time Stopping date if just before admission (a.o. important for anticoagulants) Route of administration Time(s) of adminitration (hours) Caution with drugs that are not taken every day (1x/week, 1x/month ): e.g. methotrexate, biphosphonates, ertyhropoetin Anticoagulants antiaggregants: Vitamine K antagonists LMWH Aspirin, clopidogel, prasugrel, Ask specifically for: Anticoagulants Inhalators Plasters Eye, ear and nose drops Ointments Vitamines Painkillers (chronic / if needed) Insulin Sleeping pills Drug information sources: Intranet: drug information provided by the hospital pharmacy 3. Drug information sources via Intranet (Farmacotherapeutisch Kompas, UpToDate) 24 24

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27 MEDICATION BAG 27 27

28 Step 2: medication review For older hospitalized patients with polypharmacy After medication reconciliation at EM At the geriatric ward For ILT patients - different hospital wards 28 28

29 Medication review in practice Preparation (adapted MAI) at the pharmacy (data from electronic patient file) by junior clinical pharmacist Discussion of the proposed recommendations with experienced clinical pharmacist Electronic transfer of the adapted MAI table to geriatrician(s) Recommendations to treating hospital physician by phone + note in the electronic patient file Recommendations to the general practitioner in a pharmaceutical discharge letter 29 29

30 Indication Appropriate choice Dose Correct modalities Drug-drug interactions Duration of therapy Weight ADRs Total score Contraindication Recommendation 1 Molsidomine 16 mg 1x 0 0 1, ,5 Stop 2 Nitroglycerine 10 mg TD 1x Isosorbidedinitrate 5mg PRN Bumetanide 0,5 mg 3x/w ,5 0 0,5 0,5 1 3,5 Stop 5 Perindopril 4 mg 1x , ,5 Decrease dose 6 Carvedilol 25 mg 1x , ,5 Stop, switch 7 Simvastatine 40 mg 1x ,5 0,5 0 2 Decrease dose 8 Aspirine 80 mg 1x Omeprazole 20 mg 1x , ,5 10 Risperidone 0,5 mg 2x , ,5 Stop slowly 11 Escitalopram 10 mg 1x 0 0 1, ,5 12 Venlafaxine 75 mg 2x , ,5 Stop slowly 13 Lormetazepam 2 mg 1x Decrease dose 14 Prazepam 5 gtt 3x 1, ,5 Stop slowly 15 Methylprednisolone 8 mg 1x 1, ,5 Stop slowly 16 Paracetamol 500 mg PRN Lactulose 15 ml 3x 1, ,5 Stop 18 Alendronate 70mg+VitD 2800IE 1x/w 0 2 1,5 2 0, Stop, switch 19 Budesonide inh 200 mcg 1x , ,5 20 Formoterol inh 12 mcg 2x , ,5 Mean score 0,20 0,18 0,43 0,43 0,13 0,45 0,25 0,45 51,5 Undertreatment?

31 Groter 31 31

32 Medication review quiz short patient cases: drug lists find the drug related problem(s) for each case 32 32

33 1. Case 1: woman, 75 years 1. Furosemide 40 mg 1x every two days 2. Bisoprolol 10 mg 1x 3. Hydrochlorothiazide 25 mg 1x 4. Paracetamol 500 mg PRN 5. Levomepromazine 25 mg 1x 6. Allopurinol 300 mg 1x 7. Lorazepam 1mg 1x Thiazides not in case of gout (STOPP criteria) 33 33

34 2. Case 2: man, 78 years 1. Indapamide 2.5 mg 1x 2. Spironolacton 25 mg 1x 3. Levothyroxine mg 1x 4. Digoxin mg 1x 5. Carvedilol 12.5 mg 1x 6. Amitriptylin 25 mg 1x 7. Zopiclon 10 mg 1x Undertreatment: ACE inhibitor for heart failure (START criteria) 34 34

35 3. Case 3: man, 79 years 1. Warfarin ~ INR 2. Verapamil SR 240 mg 1x 3. Nitrazepam 5 mg 1x 4. Digoxin mg 1x 5. Ibuprofen 600 mg PRN 6. Lactulose 30 ml 1x ADR verapamil: chronic obstipation ( medication cascade ) AF: betablocker instead of digoxin? Stop digoxin and verapamil; start betablocker 35 35

36 4. Case 4: Woman, 81 years 1. Glibenclamide 5 mg 2x 2. Enalapril 20 mg 1x 3. Altizide 15 mg / spironolactone 25 mg 1x 4. Calciumcarbonate 500 mg 1x 5. Cholecalciferol 400 IE 1x 6. Simvastatin 20 mg 1x 7. Cotrimoxazol 400/80 mg 1x Interaction glibenclamide - cotrimoxazole: risk of hypoglycemia Risk of hyperkaliemia (enalapril, spironolactone), certainly in case of decreased renal function 36 36

37 5. Case 9: Woman, 89 years 1. Theophylline 300 mg 1/d 2. Digoxin 125 mcg 1/d 3. Lisinopril 20 mg 1/d 4. Lormetazepam 1mg 1/d 5. Paracetamol 1g 3/d 6. Tramadol 50 mg PRN 7. Piroxicam 20 mg PRN Dose reduction (decreased renal function 30ml/min) Lisinopril: 10 mg, Tramadol: Q12h Check digoxin and theophyllin Stop piroxicam 37 37

38 6. Case 10: Woman, 80 years Warfarin ~ INR Aspirine 100 mg 1/d Ramipril 5 mg 1/d Felodipine 10 mg 1/d Metoprolol 100 mg 1/d Gliquidon 30 mg 2/d Gliclazide SR 60 mg 1/d Venlafaxine 75 mg 2 /d (-10 days) Hospital admission: confusion ADR venlafaxine: hyponatriemia (SIADH) NB choice of antidepressant 38 38

39 In conclusion Medication review for selected patients (chronic drugs, polypharmacy) Steps: medication reconciliation medication review recommendations Combination of explicit and implicit approach: PIM drugs and MAI questions Standardized method THANK YOU FOR YOUR ATTENTION 39 39