Medication Trouble Shooting in General Practice

Medication Trouble Shooting
in General Practice
General Practice in Ireland
•
2,500 GPs/practice nurses
•
15,000,000 consultation per year
•
90% use electronic health record
Heart Failure in Ireland
Prof Ken McDonald 2007
Do we have the right diagnosis?
Access to diagnostics limited in primary care
Effect on treatment choice
Effect on drug choice
Effect on drug doses
Do we have the right diagnosis?
What is the aim for
ACE inhibitor dosage?
Aim ramipril 10mg
Aim BP <140/90
Have we considered non drug therapy?
Ex-smokers and non-smokers with heart failure have a 30% lower mortality than those who
smoke and have heart failure
Exercise improves symptoms and quality of life in heart failure
Suskin N, Sheth T, Negassa A, Yusuf S Relationship of current and past smoking to mortality and morbidity in patients with left ventricular dysfunction JACC
2001;37:1677-1682
Do we know the right drugs for this patient?
Clinical Trials vs Real World
Badano LP et al. Patients with chronic heart failure encountered in daily clinical practice are different from the "typical" patient enrolled in therapeutic trials.
Ital Heart J. 2003 Feb;4(2):84-91.
RALES study & hyperkalaemia admissions
Juurlink
et al Rate of hyperkalemia after publication of the randomised aldactone evaluation study
Extending trial findings to other groups
Combination of ACEI and ARB can be used in advanced heart failure and diabetic
nephropathy
BUT!
•86.4% of patients did not have a trial indication
•Renal dysfunction more common HR 2.36 (1.51-3.71)
•Hyperkalaemia more common HR 2.42 (1.36 to 4.32)
•Median duration of combination therapy: 3 months
McAllister et al. The safety of combining angiotensin-converting- enzyme inhibitors with angiotensin-receptor blockers in elderly
patients: a population-based longitudinal analysis CMAJ 2011. DOI:10.1503 /cmaj.101333
Are the drugs being taken?
Patients with resistant hypertension (>3
antihypertensive drugs)
Average BP 156/106mmHg
Informed that drug intake being monitored
for 2 months
NO change in drug therapy
After 2 months
Mean BP 145/97mmHg
BP <140/90 in 33% of patients
?
Burnier M et al Electronic compliance monitoring in resistant hypertension: the basis for
rational therapeutic decisions. J Hypertension 2001;19:335-341
Adverse effects and how to deal with them
Which are important?
Are they temporary or permanent?
Medication guides
Potentially inappropriate drugs
What is the aim for medications?
Improve symptoms
ACE inhibitor
Improve
prognosis
✓
ARB
✓
✓
Beta blocker
✓
✓
Aldosterone
antagonist
Digoxin
✓
✓
X
✓
Diuretic
X
✓
✓
Monitoring
What is required?
Is it possible?
Patient education about need for
monitoring
What does the patient want?
What does the patient want?
•
May not be identical for each person with the same diseases
•
May change over time
•
Evidence of effect?
•
Patient values and life circumstances
Hypertension
Heart
Failure
COPD
Chronic
Kidney
Disease
Epilepsy
IHD
Arthritis
Diabetes
Stroke
Asthma
People
Single patients
Multiple diseases
•COPD
•Hypertension
•Diabetes Mellitus
•Osteoporosis
•Osteoarthritis
It’s Not Easy Living with Multimorbidity
Time
Medications
Non-pharmacologic Therapy
All Day
Periodic
7 AM
Ipratropium MDI
Alendronate 70mg weekly
Check feet
Sit upright 30 min.
Check blood sugar
8 AM
Eat Breakfast
HCTZ 12.5 mg Lisinopril 40mg Glyburide
10 mg ECASA 81 mg
Metformin 850mg
Naproxen 250mg
Omeprazole 20mg
Calcium + Vit D 500mg
2.4gm Na, 90mm K, Adequate Mg, ↓
cholesterol & saturated fat, medical
nutrition therapy for diabetes, DASH
Joint protection
Energy conservation
Exercise (non-weight bearing
if severe foot disease, weight
bearing for osteoporosis)
Muscle strengthening
exercises, Aerobic Exercise
ROM exercises
Avoid environmental
exposures that might
exacerbate COPD
Wear appropriate footwear
Albuterol MDI prn
Limit Alcohol
Maintain normal body weight
Pneumonia vaccine, Yearly influenza
vaccine
All provider visits:Evaluate Self-monitoring
blood glucose, foot exam and BP
Quarterly HbA1c, biannual LFTs
Yearly creatinine, electrolytes,
microalbuminuria, cholesterol
Referrals: Pulmonary rehabilitation
Physical Therapy
DEXA scan every 2 years
Yearly eye exam
Medical nutrition therapy
Patient Education: High-risk foot conditions,
foot care, foot wear
Osteoarthritis
COPD medication and delivery system
training
Diabetes Mellitus
12 PM
Eat Lunch
Ipratropium MDI
Calcium+ Vit D 500 mg
Diet as above
5 PM
Eat Dinner
Diet as above
7 PM
Ipratropium MDI
Metformin 850mg
Naproxen 250mg
Calcium 500mg
Lovastatin 40mg
11 PM
Ipratropium MDI
Boyd, JAMA 2005;294:716-724
21
How to deal with co-morbidities
Clinically dominant co-morbid conditions:
so complex or serious that they eclipse the management of other health problems
– end-stage, severely symptomatic, recently diagnosed
Concordant conditions:
represent parts of the same overall pathophysiologic risk profile and are more likely to be
the focus of the same disease management plan
Discordant conditions:
not directly related in either their pathogenesis or management and do not share an
underlying predisposing factor
Symptomatic versus asymptomatic chronic comorbidities
Piette JD and Kerr EA Diabetes Care 29:725-731, 2006
“He is now taking a total of 12 tablets which he is struggling to finance as he is
unable to work”.
“He takes 6 tablets in the morning, 2 at lunchtime, 1 after dinner
and 3 at bedtime. Some of them need to be taken before food and
some after, so he finds it difficult to plan”.
“If I’m going on a long trip on the bus, well, I never take one
(frusemide) in the morning because you have to keep going to the
toilet. So if I’m going a long way I miss the morning dose”.
“He continues to question whether his treatments are
really necessary and is beginning to wonder whether all this
effort is really worth it”.
RMS Titanic
Text
SS Eastland
Thank you!