OHSU InernalHarmful polypharmacy Medicine ReviewArthur D. Hayward, MD, MBA OHSU InernalHarmful polyp Medicineharmacy ReviewArthur D. Hayward, MD, MBA OHSU

InernalI have nothing Medicine to disclose. Review Case Study: DoesOHSU Verda need pravastatin? Inernal Medicine Review Outline (And, But, Therefore)OHSU

• Our era of medicine is dominated by new and powerful drugs • InernalBut drug overuse risks harm Medicine • We must use drugsReview judiciously and cautiously. The EnlightenedOHSU Era of Drugs

• Previously untreatable diseases are now treatable, and • FormerlyInernal hospitalized are now Medicinetreatable as outpatients, and • Longevity has increased, and • Some costs have decreased. (?) • But… Review But…Do we overemphasizeOHSU drugs? • Commercialization and its imperatives* • Medicalization of normal states and conditions • MisleadingInernal claims and marginal Medicine benefits • Increased risk of adverse effects1 * • Rising costs* • Neglect of non-drugReview treatment2 * • Public Disillusionment

1Qato DM. JAMA Intern Med. Changes in Prescription… 2016 Apr;176(4):473-82. 2Ioannidis. Comparative Effectiveness of Exercise…BMJ 2013;347:f5577 Commercialization Increase revenue (shareholderOHSU value) • Invent new drugs • Sell more current drugs • Increase demand • Expand the market Inernal• Add indications (antipsychotics) Medicine • Extend treatment (statins, opioids) • Ensure Insurance coverage (Medicare, private insurers) • Penetrate more of the existing market (statins) • Advertising and promotion1 • Direct to consumers ($2.1 to 9.6B) • To opinion leaders and prescribers ($15.6 to 20.3B) • Help generate and promoteReview guidelines • Lower prices?? • Outcompete • Extend patents • Raise prices

1Schwartz LM, Woloshin S. Medical Marketing… 1997 to 2016. JAMA. 2019;321(1):80-96 Promotion/ Advocacy/OHSU Hype • The term “miracle drug” came into use around 1944 to refer to a substance “that elicits a dramatic response in a patient’s condition”. (Merriam Webster Dictionary) • InInernal 2015 in one 4-day span 94 articlesMedicine from 64 distinct news outlets used “miracle” or synonyms like “break-through” or “game changer” referring to 36 specific new oncology drugs, half not yet approved by the FDA and severalReview not trialed in humans.

Abola MV, Prasad V. Research Letter. JAMA Oncol. 2016:2(1);139-141 Changes in Medical Marketing Costs 1997 -2016 OHSU Inernal Medicine Review Rising costs of drugsOHSU • In 2016 the US spent $3,337 billion on national health expenditures and $329 billion on prescription drugs1. •InernalCMS projects spending for retailMedicine prescription drugs will be the fastest growth health category over the next decade2. Review

1Hartman, M et al. National Health Care Spending…. Health Affairs 37(1):150-160. Jan 2018 2Cuckler G et al. National Health Expenditure…Health Affairs 37(3); March 2018. New Drug ApprovalsOHSU Drug sales Pharma Inernal Medicine

Experts Prescribers and ReviewAdvocates

FDA Approval Podcast: Vinay Prasad Drug Dissemination

DrugOHSU sales Pharma $$ $$ Inernal Medicine

PrescribersReview Experts

Coverage, Guidelines Adverse Drug EffectsOHSU (ADEs) • Pre-approval Phase Three trials may not detect infrequent ADEs. • Interactions may be unpredictable, multiple. • ADEsInernal can be undetected/ under Medicine-reported in clinical practice. • Prescribing patterns often do not change despite known risks. • Anticholinergics and antipsychotics in patients with dementia • Mistaking ADEs as new problems to be treated risks creating the prescribing cascade.Review The Prescribing Cascade OHSU Inernal Medicine Review Do we neglect nonOHSU-drug treatment? Inernal Medicine Review

Ioanidis J. BMJ 2013;347:f5577 doi: 10.1136/bmj.f5577 (Published 1 October 2013) Polypharmacy in Preventive Cardiology1 OHSU Inernal Medicine Review

1J Am Coll Cardiol 2015;66:1273 European Association of Preventive Cardiology

Exercise training recommended for Type II diabetics with CV diseaseOHSU • Target dysglycemia, dyslipidemia, arterial hypertension, obesity, reduced cardiovascular fitness • ImproveInernal insulin sensitivity, lipid profile, vascular Medicine reactivity, CV fitness, (inflammation?) • Mounting evidence (200+ references) • => Prescribe exercise training • Review How-to recommendations based on individual patient profiles.

https://doi.org/10.1177/2047487318820420 (Euro J of Prev Cardiology Jan. 14, 2019) Therefore…?? OHSU A. Scrutinize literature carefully and skeptically. B. Consider drug alternatives1. C. InernalUse safer drugs2. Medicine D. Investigate possible adverse effects in your patients. E. Consider time-to-benefit vs longevity when prescribing. F. Deprescribe? Review

1 Trauer JM, Cunnington D. CBT for Chronic Insomnia… Ann Intern Med. 2016 Jan 19;164(2):134-5. 2Hanlon JT, Semla TP, Schmader KE. J Am Geriatr Soc. Alternative Medications… 2015 Dec;63(12):e8-e18. Scrutinize Clinical Trials Carefully 1. Doublecheck fundingOHSU sources and disclosures. 2. Consider methodology a. Note Exclusions. I. By age InernalII. By co-morbidities Medicine b. Is statistical significance clinically meaningful? 3. Ask whether findings have been reproduced in subsequent studies. 4. Consider misconductReview including falsification of data1.

1Seife C. Research misconduct identified by the US Food and Drug Administration: out of sight, out of mind, out of the peer-reviewed literature. JAMA Intern Med. 2015;175(4):567-577. doi:10.1001/jamainternmed.2014.7774 Last Observation Carried Forward OHSUMethodology Inernal Medicine Cognitive Dropouts with LOCF function Review

Dropout Measure Time

Kaduszkiewicz H, Zimmermann T, Beck-Bornholdt HP, van den Bussche H. Cholinesterase inhibitors for patients with Alzheimer’s disease: systematic review of randomized clinical trials. BMJ. 2005 Aug 6;331(7512):321–7. “Statistical Error Type 3”

The statisticalOHSU B difference in A Inernaloutcome A… Medicine…is less than meaningful clinical Review benefit B

Control Intervention

See Lin JS, O’Connor E, et al. “Screening for Cognitive Impairment…”Ann Intern Med. 2013;159(9):601-612. Failures of Replication OHSU The Decline Effect Ioannidis Reviewed 49 high impact treatment or prevention studies 1990 - 2003 - 5 found no benefit Inernal MedicineOf 44 studies claiming benefit… - 11 not repeated - 7 contradicted - 7 found less efficacy => 14 of 33 (42%) of positive Review studies not confirmed Therefore…Deprescribe?OHSU

Inernal• Yes? (benefits) Medicine • Why Reviewnot?? (obstacles) Benefits Reduce OHSU • Pill Burden • confusion • risks of potential adverse and of under-recognized Inernaldrug effects Medicine • paperwork and tasks of drug reconciliation • costs of care • nursing burdenReview Increase • Use of non-drug treatment • therapeutic alliance Obstacles to DeprescribingOHSU • Profiling and guidelines • Reversing decisions by other prescribers Inernal• Self-contradicting previousMedicine decisions • Time constraints • Patient choice…some of the time • TreatmentReview imperative Why Don’t (VA) PCPsOHSU Deprescribe? Survey results: Lack of awareness Inernal(39% not aware tight glucose control Medicine harms older adults) Fear of bad report card (42%) Fear of legal liability (25%) Not enough timeReview to discuss (30%)

JAMA Intern Med. 2015;175(12):1994-1996. doi:10.1001/jamainternmed.2015.5950 OHSU Why and how we/ you deprescribe? Inernal Medicine Review How? • Solicit patientOHSU ideas and priorities • Go Step-by-Step • Offer alternatives Inernal• Get help* Medicine • Pharmacy specialists • Consult authoritative sources • Follow-upReview • Add “polypharmacy” to the problem list 2019 updated Beers Criteria

OHSUFor adults 65 and older

1. Evidence scheme 2. Potentially inappropriate in most 3. Drug Disease issues Inernal Medicine4. Use with caution 5. Drug-Drug issues 6. Renal toxicity concern 7. Anticholinergics Review8. Meds removed 9. Meds added

http//:deprescribing.org

J Am Geriatr Soc. 2019 Jan 29. doi: 10.1111/jgs.15767. [Epub ahead of print] Non-Drug Treatment For Behavioral and Psychiatric Symptoms of DementiaOHSU (BPSD)1 Psychosocial practices Sensory • Validation therapy • Massage • Reminiscence therapy • Multi-sensory Inernal Medicine• Music therapy • Aromatherapy • Pet Stimulation • Meaningful activities • Bright light Structured care protocols Review• Bathing • Mouth care

1Scales, et al. Gerontologist, 2018, Vol. 58, No. S1, S88–S102 Individualized Nurse Non-Drug Treatment Interventions • For BPSD1 OHSU• Model desired behavior • Sensory • Massage • Avoid arguing • Multi-sensory • Aromatherapy • Engage in social interaction • Stimulation Inernal• Bright light • MedicineUse non verbal communication • Psychosocial practices • validation therapy • Identify and avoid triggers • reminiscence therapy • music therapy • Redirect • pet • meaningful activities Review• Recruit for “meaningful” activity • Structured care protocols • bathing • Provide live or inanimate pets • mouth care

1Scales, et al. Gerontologist, 2018, Vol. 58, No. S1, S88–S102 Case Study: DoesOHSU Verda need pravastatin? Inernal Medicine Review

Michael A. Steinman; Joseph T. Hanlon Managing Medications in Clinically Complex Elders "There's Got to Be a Happy Medium" http://jama.ama-assn.org/cgi/content/full/304/14/1592 JAMA. 2010;304(14):1592-1601 (doi:10.1001/jama.2010.1482) Finding the balance between benefits and harms from statinsOHSU for primary prevention A “balance modeling” study Individualizes statin therapy recommendations Inernalby drug, patient age, sex, and calculated Medicine risk of ADEs and CV outcomes, including weighted preferences using these data sources: CV risk calculations, meta-analysis of statin trials, and observational studies, time horizons, and weightings from surveys of patient preference Review to generate granulated heat maps.

Yebyo HG et al. Finding the Balance Between Benefits and Harms When Using Statins for Primary Prevention of Cardiovascular Disease. Ann Intern Med: 2019;170:1-10. Probabilities at which statin therapy for primary prevention of CVD is likely OHSU to provide net benefits among 1120 subgroups of women based on age 40 - 75, CVD risk (1% to 40%), statinInernal type, and potential Medicine for drug harm. Review If Verda is 75 years old there is no 10-year CV risk level at which benefitsOHSU outweigh risks Inernal Medicine Review Conclusions Pharmaceutical productsOHSU have greatly assisted prescribers in relieving the burdens of illness.., BUT Inernalclaims of benefits can overstate Medicine their efficacy and tend to understate potential harms... THEREFORE, prescribers are obligedReview to carefully weigh both scientific claims and patient preferences and to recognize that the best treatment is sometimes not a drug. OHSU Questions? Inernal Medicine Review