<![CDATA[AskaPharm Medication Reviews - Blog]]>Tue, 05 Dec 2017 07:02:28 -0800Weebly<![CDATA[Thinking long-term in the terminally ill]]>Tue, 18 Aug 2015 21:16:24 GMThttp://askapharmmedicationreview.com/blog/thinking-long-term-in-the-terminally-ill
Sounds counterintuitive to think long-term when dealing with the terminally ill. But recent research indicates that cancer patients are some of the most medicated individuals within our healthcare system. A study in over 4000 individuals in hospices in 11 states (35% of which had a cancer diagnosis) demonstrated that a mean of 15 drugs had been prescribed at any one time. More than 350 patients were receiving more than 30 medications (1).
To some degree this is due to the continued use of medications previously prescribed to manage chronic conditions despite the possibility of no longer being of benefit. An irish study (2) showed that individuals within a week of dying were prescribed a mean of ten drugs. All too often, treatment with these medications no longer makes any sense given the physical state of the individual. Medication profiles are often ignored as patients approach their final weeks or months of life. Without a doubt, medication reviews are all but forgotten.
Medications that treat or prevent conditions that have a long-term impact on health becomes unnecessary and actually adds to the burden in the short-term. For example, one has to ask whether it makes sense to treat for increased cholesterol levels, mild-to-moderate hypertension or osteoporosis. All these conditions have negative health consequences in the long-term but have little impact in the short-term. In fact, treating these conditions is likely to increase side effects and drug interactions or reduce quality of life in the short-term. 
In fact, another study conducted by the US Palliative Care Research Cooperative (3) group demonstrated that in individuals where cholesterol drugs (statins) were stopped, life expectancy was not affected. In these patients, quality of life (McGill QOL scale) was significantly better than in those still taking a statin drug. Furthermore, the group projected that, in the U.S., if statins were discontinued in patients with less than 1 year to live, a total yearly savings would be in the order of $600 million (est. 2012 terms).
Although little research exists regarding polypharmacy and its burden in the advanced cancer population, healthcare professionals should periodically review medications to assess whether they are necessary in patients with cancer or nearing the end of life. Patient life expectancy should be considered when evaluating drugs that provide probable benefit not until years beyond their anticipated lifespan.  
1) Sera L, McPherson ML, Holmes HM. Commonly prescribed medications in a population of hospice patients. Am J Hosp Palliat Care 2014; 31: 126–31.
2) McLean S, Sheehy-Skeffi ngton B, O’Leary N, O’Gorman A. Pharmacological management of co-morbid conditions at the end of life: is less more? Ir J Med Sci 2013; 182: 107–12. 3) Kutner JS, Blatchford PJ, Taylor DH Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med 2015; 175: 691–700.
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<![CDATA[The source of adverse events is not always apparent]]>Tue, 28 Jul 2015 18:06:00 GMThttp://askapharmmedicationreview.com/blog/the-source-of-adverse-events-is-not-always-apparent
The need to review an elderly person's medication periodically cannot be overstated. And, the need to be thorough is equally important. Let me tell you about a case that illustrates this very well. 
Mrs. S.C. is an 85 year old woman that enjoyed a relatively independent lifestyle except for a little help from her daughter with financial matters. She was in fairly good health but suffered from hypertension, constipation, arthritis and hemorrhoids.
Unfortunately she had a recent setback due to a bedside fall and a resulting right hip fracture. She also developed post-operative confusion and was newly diagnosed with dementia. After a week of rehabilitation for her hip fracture, Mrs. S.C.'s endurance began to wane. Her blood pressure appeard to be low, 86/50, and one of her anti-hypertensive medications was discontinued. Her cognitive function appeared to also be worsening. As such, she discontinued her rehabilitation program. She continued to have low blood pressure which manifested as frequent lightheadedness, especially when she rose from a seated or horizontal position. A medication review did not reveal anything untoward with regards to her therapies. A few days later, Mrs. S.C.'s daughter revealed an ointment that her mother used twice daily to relieve her hemorrhoids. The ointment was originally discounted from the medication review as Mrs S.C. and her daughter both thought it played an insignificant role in her overall treatment regimen. 
The ointment in question was prescribed some time ago and was nifedipine-based. The latter drug when administered orally is used to treat hypertension. In the treatment of hemorrhoids, nifedipine is used to constrict blood vessels in the rectal region and as a result helps to provide relief of symptoms. Given that a certain fraction of topically applied nifedine can be absorbed, the ointment was stopped and replaced with another non-nifedipine based ointment. Her low blood pressure returned to normal and the symptoms of lightheadedness resolved. Her cognitive status improved dramatically over the course of several weeks and she returned to her rehabilitation program.  
When exploring an individual's medication profile, always air on the side of caution. Better to be more inclusive when declaring the medications being consumed. Include OTC, supplements, topicals, as well as infrequently taken medications (e.g. injectables taken on a monthly or semi-annual basis). This will ensure a more thorough medication review and ultimately could help in identifying the source of an adverse event.
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<![CDATA[The flip side of treating Alzheimer's]]>Wed, 08 Jul 2015 03:40:23 GMThttp://askapharmmedicationreview.com/blog/the-flip-side-of-treating-alzheimers
Here's a scary thought; the global prevalence (the proportion of individuals that have a specific condition at any given point in time) of Alzheimer's Disease (AD) is expected to quadruple in the next 35 years. That's a lot of people if you consider 5.2 million Americans had AD in 2014. One in nine people over the age of 65 has AD*. 
One of the more intriguing concerns with the treatment of AD is how we deal with the psychiatric behavioural problems. And this is not a rare occurence, as behaviour problems are believed to occur in about 70% of individuals with AD.
A newer class of drugs called the atypical antipsychotics are often used to treat behaviour problems such as anger, aggression, or delusions/hallucinations.
These types of problems have been suggested as having an even greater impact on caregiver burden than problems related to cognition or daily function. What's more, behaviour problems can also significantly contribute to the decision of institutionalizing an individual with AD. 
And so, it becomes very important to figure out the best way to treat such problems. The usual recourse is the use of atypical antipsychotics such as Risperdal (risperidone) or Abilify (aripiprazole). But the use of these medications is not without a certain degree of controversy. Many experts wonder about their long term use and whether they possibly contribute to a worsening of the overall dementia condition. Others wonder whether their high cost actually justifies their use, particularly given the lower cost of older antipsychotic medications. 
While the controversy goes on, healthcare professionals are often caught between a rock and a hard place. Regardless of where professionals stand on the issue, treatment decisions must be made. One thing that seems for certain is that these medications seem to provide some benefit in alleviating behaviour problems. But this positive outcome is not without an increase in the risk of adverse events. After a hard look at many studies, researchers recently confirmed that the use of atypical antipsychotics also elevate the risk of somnolence, urinary tract infections, urinary incontinence, edema and abnormal gait. It should be pointed out that this risk in not insignificant - up to a 50% increase in adverse event risk in some instances**. As with most drug therapies, there are two sides to this treatment story, that is, a benefit and a risk.
As a caregiver it is important to be aware of such adverse events if your loved one is being treated for behaviour problems. Recognizing and discussing these adverse events with the treating physician may lead to better treatment or intervention strategies. Physicians should treat with a 'start low go slow' strategy to minimize these potential risks. Ask the treating physician if the dose is a minimal dose when initiating treatment. If an adverse reaction develops, make sure the physician considers the possible adverse effects associated with the antipsychotic medication. Be sure to consider a medication review in order to help optimize therapy and minimize the likelihood of adverse events in individuals with Alzheimer's Disease. 
* 2014 Alzheimers Disease, Facts and Figures, Alzheimer's Association. Washington, DC. www.alz.org. 
** Tan et al. Alzheimer's Research & Therapy (2015) 7:20
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<![CDATA[Cheating our seniors...]]>Sat, 27 Jun 2015 01:15:44 GMThttp://askapharmmedicationreview.com/blog/cheating-our-seniors
Could some of our treatments actually be cheating or bamboozling our seniors? Yes, I think so. Maybe not all individuals being treated for urinary incontinence, but quite a few. Let me explain.
Urinary incontinence or the inability to be able to defer the urgency to pass urine is a relatively common problem among men and women over the age of 60. It affects about one in five individuals in that age group. 
The condition requires immediate attention as neither the afflicted individuals nor the immediate family is willing to deal with the consequences. Treatment quite often involves the use of a medication called oxybutynin. Not only does this agent have a proven track record (an old standard physicians are used to prescribing) it also happens to be cheap. In fact, several medical guidelines (e.g. National Institute for Clinical Excellence, NICE) recommend its use as a first-line agent. It's no wonder physicians feel good about recommending it. 
The trouble is, oxybutynin is often associated with cognitive decline. While we might be reducing the urge to urinate on the one hand, on the other, we are reducing a person's ability to process information in a normal manner. Oxybutynin is able to cross the blood brain barrier and get into brain tissue. This barrier is more permeable in the elder and puts this population particularly at higher risk for psychologically related adverse events. More selective agents (medications acting principally on the bladder with little effect on the brain) are available but these are most expensive. As such, payers (private and public) will often preferentially reimburse oxybutynin and only cover costs for more expensive and more 'bladder selective agents' if patients fail to respond or cannot tolerate oxybutynin.  
To make matters worse, a decline in cognition is often overlooked by physicians or family. In other words, the decline in cognition may be noticed but is often associated with the aging process and not with the secondary adverse effects of a medication used to treat urinary incontinence. So, while we think a person's mental capacity is declining due to age, in reality, his or her mind is fading as a result of side effects related to the drug used to treat urinary urges. In fact, while medication review criteria have listed oxybutynin as a potentially inappropriate medication, it continues to be used for its efficacy and low cost without regard for its negative effects on cognition.
And so, could we be cheating some of our seniors? You bet we are.
Source: Gibson, et al. Int J Clin Pract, September 2014, 68, 9, 1165–1173
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<![CDATA[A question your physician needs to remember.]]>Wed, 24 Jun 2015 15:11:16 GMThttp://askapharmmedicationreview.com/blog/a-question-your-physician-needs-to-remember
Diuretics are used to treat a number of conditions including hypertension and edema. Now, imagine Mrs. Jane Doe who is prescribed hydrochlorothiazide, a diuretic, to better control her high blood pressure. In a subsequent check-up, her physician notices that results from a blood sample analysis reveals a high level of uric acid. Hyperuricemia is indicative of gout. In good faith, Mrs. Doe's good doctor decides to prescribe allopurinol, an anti-gout medication that will help reduce uric acid to a more normal level. 
In turns out that diuretics are often the source of increased levels of uric acid. It turns out Mrs. Doe's doctor has failed on two counts: 1) he misinterpreted the diuretic's hyperuricemic effect as a new medical condition, that is, gout and 2) there is no need to treat the increased uric acid level unless it becomes symptomatic. 
This is an example of the prescribing cascade which leads to the consumption of inappropriate medication. In this case, a better approach would have been to reduce the dose of the diuretic (and/or perhaps add another antihypertensive if needed to regulate blood pressure) or find an alternative medication that is not associated with increases in uric acid. 

Many more examples of prescribing cascades exist. As such, before initiating a new medication, all physicians need to ask themselves one important question: 'Is this new medication being used to treat the effects of another drug'.
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<![CDATA[Prescribing cascade and falls in the elderly]]>Sun, 21 Jun 2015 19:10:20 GMThttp://askapharmmedicationreview.com/blog/prescribing-cascade-and-falls-in-the-elderly
An Australian study* published a few years ago demonstrates how the prescribing cascade can lead to falls in the elderly. The prescribing cascade occurs when an adverse event is confused or misinterpreted as a new medical condition and, as a result, another medication is prescribed to counter the effects on the causitive medication. A good example of this frequent problem is illustrated in this study. Investigators identified a number of elderly individuals that had developed dizziness and nausea.
Medications such as antidepressants or antihypertensives are often the cause of nausea and dizziness. A medication called prochlorperazine is often used to counter nausea and dizziness. In this study, individuals were given prochlorperazine as a results of dizziness caused by the medications they were taking. These individuals were followed for 4 years and it was determined that when prescribed secondary to an adverse event from another medication, prochlorperazine was associated with a 50% increase in hip fractures. To make matters worse, we know that 25% of individuals having a hip fracture die within the following year. 
Many of these hip could have been prevented. A medication review would have determined that a better approach to treating dizziness and nausea would have been to reduce the dose or find an alternative to the medication causing the dizziness. 
*Pharmacoepidemiology and Drug Safety, 2010; 19: 977–982.  **Bentler SE, et al. Am J Epidemiol 2009; 170: 1290–1299
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<![CDATA[The bottom line]]>Mon, 15 Jun 2015 00:52:26 GMThttp://askapharmmedicationreview.com/blog/the-bottom-line
If you have visited our website you are probably aware that taking multiple medications or polypharmacy increases your likelihood of experiencing adverse drug events and/or side effects. While it is important to take your medication as directed to treat your medical conditions, it is equally important to manage your medications to help minimize the possiblity of developing medication related problems. And so, what exactly are some of these problems that can arise from taking numerous medications. Well, the bottom line is that there are many potential problems. But the good news is that most can be prevented by having periodic medication reviews. Having said that, let's have a closer look at these complications.
While adverse events are a more obvious consequence of taking multiples medications, others may be lesser known but of significant importance. Among these are increases in: heathcare cost, drug interactions, non-adherence or lack of compliance, falls, congnitive impairment, urinary incontinence, and malnourishment. A decrease in functional status or ability to perform activities of daily living is also associated with taking multiple medications. Over the next few posts we will examine these consequences in more detail and also highlight the so-called 'culprit' drugs associated with some of these complications
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<![CDATA[Sunshine Vitamin - an often forgotten therapy]]>Sun, 14 Jun 2015 21:43:54 GMThttp://askapharmmedicationreview.com/blog/sunshine-vitamin-an-often-forgotten-therapy
Although older adults are prone to potentially inappropriate medications (PIMs), they are also subject to potential prescribing omissions (PPOs). The latter consist of therapies that should be included as part of an individual's overall treatment, but for some reason are missing. Although PIMs can play a role in developing side effects or adverse events, PPOs are equally important if a condition goes unnoticed or untreated.
A recent study* of over 300 individuals aged 75 years or older indicated that calcium and vitamin D are often forgotten therapies. More than 13% of individuals with osteoporosis had vitamin D and calcium omissions. This is particularly distressing given that both these agents are the backbone of treatment in people with osteoporosis. Another equally alarming observation is the fact that almost one in five (18.3%) individuals prone to falls were prescribed a benzodiazepine - Valium is an example you are likely familiar with. This class of drugs is associated with sedationand confusion which can reduce a person's ability to be alert and increase the likelihood of a fall. 
*San-Jose A, et al. BMC Geriatr, 2015; 15(1): 42
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<![CDATA[Two pharmacies are better than one, right?]]>Sun, 07 Jun 2015 22:10:52 GMThttp://askapharmmedicationreview.com/blog/two-pharmacies-are-better-than-one-right
Wrong! If you are like 40% of seniors, you are visiting or using multiple pharmacies for your medication needs. A recent study* done among adults over the age of 65 in Ohio shows that a significant number of seniors are using more than one pharmacy. 
Switching between pharmacies interferes with proper communication among healthcare professionals, increases the risk of inappropriate medication use and potential adverse events
To make matters worse, this study also determined that about one in five seniors were taking duplicate therapy. About the same proportion were also taking contraindicated drug combinations. 

This study suggests that a good number of older adults have problematic drug profiles. And it also suggests that a number of older adults are making it difficult for their healthcare professionals to pick up any abnormalities in the therapeutic profiles given that many are visiting different pharmacies. In other words. the pharmacists and physicians looking after such individuals mat not be 'seeing the whole picture' so to speak. Perfect candidates for a medication review, wouldn't you say.
*Golchin N, et al. Polypharmacy in the Elderly. J Res Pharm Prac, 2015; 4(2): 85-88
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<![CDATA[Why a blog?]]>Fri, 05 Jun 2015 19:20:10 GMThttp://askapharmmedicationreview.com/blog/why-a-blog
To be frank, I wasn't sure if I wanted to create a blog when I thought of developing and offering a medication review service. But the more I thought this out, the more it became evident that there is a real need to communicate current and informative dialogue about medication, particularly to those who are older adults and to those of us who are younger in caregiving roles. 
My objective with this blog is to disseminate credible and useful information about medication. Not drug facts, that information is available on medical sites such as UptoDate, Drug.com and WebMD. More real world information based on my experience as a pharmacist. More information related to the rationale for this website. To help readers make better informed decisions about the medications they are taking. To help readers better understand why they are taking certain medications. To help readers better manage their medications and ultimately to provide better health outcomes. 

I hope you enjoy the Polypharmacist blog. But a blog is better when it gets comments.

I hope to hear from you. Often.

Robert
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