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Psychotropic Polypharmacy and Physical Health

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Psychotropic Polypharmacy and Physical Health PSYCHOTROPIC POLYPHARMACY AND PHYSICAL HEALTH Michelle Cornacchia, MD Priya Chandan, MD, MPH, PhD Candidate June 29, 2018 Outline • Background & significance • Common medications & side effects • Solutions & strategies to reduce polypharmacy Outline • Background & significance • Common medications & side effects • Solutions & strategies to reduce polypharmacy Background • Polypharmacy is a major issue for individuals w/ intellectual disability (ID) • Lack of consensus regarding definition • Using five or more medications • Using more medications than medically necessary • Use of more than one medication for same indication Significance • Prevalence of polypharmacy in ID population: 11-60% • Risk factors: • Multiple co-morbidities: 2.5x the number of health issues compared to general population • Neurologic • Mental health/behavioral issues • Gastrointestinal • Cardiovascular • Endocrine • Severity of ID, place of residence, and age Pharmacotherapy for Mental Health • 40% children w/ ID had psychiatric d/o • 3-4 fold increase compared to general population • Depression, anxiety, hyperactivity d/o, bipolar d/o, & schizophrenia • 62% of individuals w/ ID had behavioral issues • Aggression, over activity, & self injury Pharmacotherapy for Mental Health • Prevalence of psychotropic drug use • 25-89% of individuals with ID • Deb et al. showed 89% of individuals with ID used psychotropic drugs with 45% having polypharmacy • Lott et al. showed 52% of medications prescribed were psychoactive: • Antipsychotics, antidepressants, & anticonvulsants Polypharmacy Based on Severity of ID, Residence, & Age • More severe ID more likely exposed polypharmacy • Mild ID 16.2% vs. profound ID 39.2% • Increased diagnosis of neurologic & psychiatric d/o • Institutionalized individuals higher rates then community dwelling • Older individuals increased risk • Co-morbidities: dementia, diabetes, HTN, osteoarthritis, & osteoporosis Outline • Background & significance • Common medications & side effects • Solutions & strategies to reduce polypharmacy Prescribing Patterns • Large number of • Combinations of medications medications • On average, 5.2 • Most common: atypical prescription medications antipsychotic + SSRI per patient antidepressant • Range from 1 to 15 • Risperidone • Fluoxetine, paroxetine, citalopram, sertraline • Psychotropic medications often prescribed at higher doses and for longer time • Indications are often periods in people with ID absent or unclear vs. general population Common medication classes • Antipsychotics • Antiepileptics • Antidepressants Antipsychotics • Most frequently prescribed psychotropic drug class in people with ID • Indications • Psychotic symptoms • Aggressive behaviors • Self-injurious behavior • Vocal and motor tics • Stereotyped behaviors • Atypical APs are often preferred due to less side effects and better tolerance • Evidence regarding efficacy and safety is limited Antiepileptics • Seizures • Aggressive behavior, • Prevalence mood stabilization • General population: 3% • People with ID: 14-44% • Efficacy evidence is limited • Efficacy evidence is limited • Providers often rely on side effect profiles when deciding which medication to use Antidepressants • Indications • Depression • Anxiety • Obsessive-compulsive spectrum disorders • Behavioral disorders (stereotypies, aggression, self-injurious behavior) • Evidence regarding efficacy and safety is limited Side Effects of Common Medications • People with ID may respond to medications at lower doses than the general population • Occurrence of side effects tends to be more frequent as compared to the general population • Common adverse effects include: sedation, insomnia, nausea, diarrhea, constipation, and weight gain • SOI medication watch list table: constipation, obesity, long QT syndrome, sun sensitivity, osteoporosis • Selph and Cosca (2016) Commonly Used Medications and their Side Effects • Medications causing constipation • Antipsychotics: clozapine, olanzapine, thioridazine, chlorpromazine • Alzheimer’s/dementia medications: memantine • Medications causing weight gain • Tricyclic antidepressants: nortriptyline, amitriptyline, doxepin • SSRIs: paroxetine, escitalopram • Other antidepressants: mirtazapine • Antipsychotics or mood stabilizers: lithium, olanzapine, clozapine, risperidone • Antiepileptics: tegretol, valproic acid, divalproex Selph & Cosca. (2016). Less is more: preventing polypharmacy in individuals with intellectual disabilities. Impact, 29(1), 28–29. Retrieved from https://ici.umn.edu/products/impact/291/291.pdf Risk Factor for Negative Outcomes • Polypharmacy can lead to • Adverse drug reactions • Drug-drug interactions • Nonadherence • Inappropriate use of medications • Psychotropic polypharmacy as a predictor of specialized inpatient admissions for people with ID receiving outpatient psychiatric services Outline • Background & significance • Common medications & side effects • Solutions & strategies to reduce polypharmacy Solutions & Strategies Systematic Tool to Reduce Inappropriate Prescribing (STRIP) Multidisciplinary approach Zaal, R. J., Ebbers, S., Borms, M., Koning, B. de, Mombarg, E., Ooms, P., Evenhuis, H. M. (2016). Medication review using a systematic tool to reduce inappropriate prescribing (STRIP) in adults with an intellectual disability: A pilot study. Research in Developmental Disabilities, 55, 132–142. Solutions & Strategies Systematic Tool to Reduce Inappropriate (STRIP) Multidisciplinary approach Zaal, R. J., Ebbers, S., Borms, M., Koning, B. de, Mombarg, E., Ooms, P., Evenhuis, H. M. (2016). Medication review using a systematic tool to reduce inappropriate prescribing (STRIP) in adults with an intellectual disability: A pilot study. Research in Developmental Disabilities, 55, 132–142. Solutions & Strategies Systematic Tool to Reduce Inappropriate (STRIP) Multidisciplinary approach Zaal, R. J., Ebbers, S., Borms, M., Koning, B. de, Mombarg, E., Ooms, P., Evenhuis, H. M. (2016). Medication review using a systematic tool to reduce inappropriate prescribing (STRIP) in adults with an intellectual disability: A pilot study. Research in Developmental Disabilities, 55, 132–142. Solutions & Strategies Systematic Tool to Reduce Inappropriate (STRIP) Multidisciplinary approach Zaal, R. J., Ebbers, S., Borms, M., Koning, B. de, Mombarg, E., Ooms, P., Evenhuis, H. M. (2016). Medication review using a systematic tool to reduce inappropriate prescribing (STRIP) in adults with an intellectual disability: A pilot study. Research in Developmental Disabilities, 55, 132–142. Solutions & Strategies Systematic Tool to Reduce Inappropriate (STRIP) Multidisciplinary approach Zaal, R. J., Ebbers, S., Borms, M., Koning, B. de, Mombarg, E., Ooms, P., Evenhuis, H. M. (2016). Medication review using a systematic tool to reduce inappropriate prescribing (STRIP) in adults with an intellectual disability: A pilot study. Research in Developmental Disabilities, 55, 132–142. Solution & Strategies • Multidisciplinary: • Physician, pharmacist, patient, and supporters • Structured medication review • Preparation of a pharmaceutical care plan • Follow up and monitoring Solutions & Strategies • Empower patient & caregiver • Know their medications & indications • Bring medication list or pill bottles • Use organizers: blister packs, dosette boxes, & alarm systems • Keep medication in sight • Document any effect of medication • Designated person to help with process Solution & Strategies • Providers: • Behavioral modifications before pharmacotherapy • Exhaust monotherapy before combination therapy • “Start low and go slow” with close follow up • Each visit review medication list • Response to therapy • Side effects • Length of therapy • Consider epileptogenic potential of medication • Appropriate instrumental (EKG) or lab work ABC Chart Antecedent Behavior Consequence Solutions & Strategies • Additional provider training in pharmacotherapy for adults with ID • Creation of developmental medicine specialty • Tools used to monitor side effects • Dyskinesia Identification System Condensed User Scale (DISCUS) Older Individuals with ID • Atypical antipsychotics are relatively contraindicated • If have history of dementia or CVA increased risk stroke • Olanzapine & quetiapine have anti-muscarinic activity • Clozapine, quetiapine, olanzapine, risperidone can cause hypotension • Known to increase risk for metabolic syndrome • Monitor blood sugar, weight, BMI, HbA1c, electrolytes, & liver function tests Other Co-Morbidities Co-Morbidity Concern Obesity/DM Metabolic syndrome (atypical antipsychotics) Seizure d/o Lower seizure threshold (clozapine, TCA, venlafaxine) HTN Elevated BP (duloxetine, methylphenidate, venlafaxine) Respiratory issues or Sedation (clozapine, dysphagia olanzapine, risperidone, & quetiapine) Considerations for Specific Disorders Trollor, J. N., Salomon, C., & Franklin, C. (2016). Prescribing psychotropic drugs to adults with an intellectual disability. Australian Prescriber, 39(4), 126– 130. Resources Conclusion • Polypharmacy is a major issue for individuals w/ ID • Commonly prescribed medications for patients with ID include • Antipsychotics • Antiepileptics • Antidepressants • Common adverse effects include: sedation, insomnia, nausea, constipation, & weight gain Conclusion • Solutions & Strategies: • Multidisciplinary medication reconciliation • Start low and go slow w/ close follow up to reassess need • Empower patient & caregiver • Empower provider References • Arvio, M., & Sillanpaa, M. (2004). Prevalence, aetiology, and comorbidity
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