< = > less is more

De-diagnosing De-prescribing Non-testing

Sue Ieraci 2017 Who says?

• • • False positives • Too much medicine • Risk aversion $$$

Sue Ieraci 2017 Sources Prof David Le Couteur, Clin Pharm and Aged Care Preventing Overdiagnosis Conference 2016

Sue Ieraci 2017 Sources • Evidence-Based Medicine 2012

Sue Ieraci 2017 Language • IMU = inappropriate medication use • IMUP = inappropriate med use w polypharmacy • PIM = potentially inappropriate medication • POM = prescribing optimisation method • ADR = adverse reactions • DDIs = drug-drug interactions • DBI = drug burden index • VOCODFLEX = very old age, the extent of comorbidity, dementia, frailty and limited life expectancy • CRIME = Criteria to Assess Appropriate Medication Use Among Elderly Complex Patients

Sue Ieraci 2017 Concept of De-Diagnosis

• Age-appropriate BP vs hypertension • Diabetic control in the elderly • Bacteruria vs UTI • Ankle oedema • “High cholesterol”

• Don’t have it -> no need to treat it.

Sue Ieraci 2017 Sue Ieraci 2017 Need to understand:

• The individual, robust vs frail, their therapeutic goals

• The benefits and risks of all of their medicines + combination

• Ethics of autonomy, dignity of risk, preferences

• Very limited evidence on the safety and efficacy of medicines in older adults, particularly in the frail, who often have multiple comorbidities and functional impairments.

• In robust older patients, therapy usually aims to delay or cure disease and to minimise functional impairment.

• In frail older patients, symptom control, maintaining function and addressing end-of-life issues become the main priorities.

Sue Ieraci 2017

Sue Ieraci 2017 Patient-based issues • Fear of change • “My doctor said I should stay on it for life” • Worry about what might happen: – “They said I could get a stroke or heart attack” – “All my friends are on it for life” • Generational: perceived benefit of medications • Perception of age discrimination

-> need explanation and reassurance cooperation with primary care provider (Help patient negotiate with PCP)

Sue Ieraci 2017 Which meds?

• Statins, gastric acid suppressive agents, angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists and inhaled bronchodilators were the most frequently ceased medications • ANTICHOLINERGICS

Sue Ieraci 2017

“Prescription cascade” • pain due to osteoarthrosis → NSAID prescribed → NSAID induces hypertension → more antihypertensive

• drug-induced nausea → metoclopramide → extrapyramidal symptoms → wrong diagnosis of Parkinson’s disease → levodopa → orthostatic hypotension (falls) and delirium → antipsychotics; dihydropyridine-induced leg edema → furosemide and potassium

• automatically prescribing H2 blockers to patients on NSAID → delirium in older people → erroneous treatment with neuroleptics

• ‘cold medications’ containing compounds with anticholinergic properties → urinary retention → α blocker → falls

(Source: Ther Adv Drug Safety 2015 Routine of chronic medications to combat polypharmacy)

Sue Ieraci 2017 Tools

• STOPP/START criteria • Beers criteria • Medication Appropriateness Index • Improved prescribing in the Elderly Tool (IPET)

Sue Ieraci 2017

Sue Ieraci 2017

Sue Ieraci 2017 Beers criteria

List of over 50 drugs or drug classes to be avoided in older ppl, incl:

Sue Ieraci 2017 Medication Appropriateness Index

Sue Ieraci 2017 BUT...risks

• Withdrawal reaction • Return of previously controlled diseases

Sue Ieraci 2017 Non-testing

• Not yet well-developed literature • Take a good history, work out likely pathophysiology, explain to patient • Discuss balance of risks – not ‘confirming’ diagnosis vs false +ve/discomfort/cost • Agree on a plan for f/up /review • (“If you still have it next week...)

Sue Ieraci 2017 Latest issue EMA Review: Probiotics to prevent antibiotic-associated diarrhoea in kids:

“ Antibiotics are commonly prescribed for children, sometimes even when clinically indicated”

“From a societal perspective, more benefit could probably be achieved by only prescribing antibiotics to children who truly need them”

Sue Ieraci 2017

Sue Ieraci 2017