Il Dott. Andrea Musu dichiara di NON aver ricevuto negli ultimi due anni compensi o finanziamenti da Aziende Farmaceutiche e/o Diagnostiche
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Il Dott. Andrea Musu dichiara di NON aver ricevuto
negli ultimi due anni compensi o finanziamenti da
Aziende Farmaceutiche e/o Diagnostiche
Dichiara altresì il proprio impegno ad astenersi, nell’ambito
dell’evento, dal nominare, in qualsivoglia modo o forma, aziende
farmaceutiche e/o denominazione commerciale e di non fare pubblicità
di qualsiasi tipo relativamente a specifici prodotti di interesse
sanitario (farmaci, strumenti, dispositivi medico-chirurgici, ecc.).
UNIVERSITA' DEGLI STUDI DI CAGLIARI
SCUOLA DI SPECIALIZZAZIONE MEDICA IN GERIATRIA
COORDINATORE: PROF.SSA ANTONELLA MANDAS
LA DEPRESCRIZIONE
DEI FARMACI NEL
PAZIENTE ANZIANO
Dott. Andrea Musu
SSM Geriatria
“As older patients move through time, often from
physician to physician, they are at increasing risk of
accumulating layer upon layer of drug therapy, as a reef
accumulates layer upon layer of coral.”
Jerry Avorn, MD
LIFE EXPECTANCY
AT BIRTH (ITALY)
World Population Prospects (2019)
ITALY: POPULATION
(AGE 65+)
World Population Prospects (2019)
CRONICITÀ
~80% of older adults have at least 1 chronic disease,
and 77% have at least 2. Four chronic diseases—heart disease,
cancer, stroke, and diabetes—cause almost two-thirds of all
deaths each year.
CDC - National Center for Chronic Disease Prevention and Health Promotion (2020)
PREVALENZA DM2
6,2%
DELLA POPOLAZIONE
2/3
NELLA FASCIA 50/80 ANNI
Osservatorio ARNO (2019)
ANDAMENTO DELLA
PRESCRIZIONE
5000 DDD uomini DDD donne 1000
Spesa lorda per utilizzatore
Spesa uomini Spesa donne
DDD/1000 utilizzatori die
4000 800
3000 600
2000 400
1000 200
0 0
65-69 70-74 75-79 80-84 ≥85
fascia d'età
Rapporto Nazionale OsMed AIFA (2019)
«GIANTS OF GERIATRICS»
Immobility Intellectual
Impairment
Instability Incontinence
Iatrogenesis
B. Isaacs (1970)
CRITICITÀ NELL’USO DEI FARMACI
Alterazioni Farmacocinetiche
Variazione del volume di distribuzione delle molecole lipo/idrosolubili
Rallentamento del transito intestinale
Riduzione del flusso enteroepatico e degli enzimi epatici
Riduzione del patrimonio di nefroni e del flusso sanguigno renale, ridotta
filtrazione glomerulare ed escrezione renale di farmaci idrosolubili
Alterazioni Farmacodinamiche
Modificazioni dell’interazione farmaco recettore
Modificazioni post recettoriali
Klotz U. Pharmacokinetics and drug metabolism in the elderly. Drug Metab Rev. (2009)
Helldén A. et al. Adverse drug reactions and impaired renal function in elderly patients […] Drugs Aging. (2009)POLIFARMACOTERAPIA,
«polypharmacy»
WHO
“The administration of many drugs at the same time or the
administration of an excessive number of drugs”
EuGMS
“Polypharmacy is defined as the use of multiple medications by
a patient, with 5 medications usually accepted as the cutoff .”NUMERO MEDIO
DI SOSTANZE
Rapporto Nazionale OsMed AIFA (2019)DISTRIBUZIONE
DEGLI UTILIZZATORI
«Between 30-40% of men
and women aged 65-85
years uses five or more
prescription medications»
Rapporto Nazionale OsMed AIFA (2019)POLYPHARMACY IN T2D
«
»
Noale, Polypharmacy in elderly patients with type 2 diabetes receiving oral antidiabetic treatment (2015)POLYPHARMACY IN T2D
Dobrica, Polypharmacy in Type 2 Diabetes Mellitus: Insights from an Internal Medicine Department (2019)POLIFARMACOTERAPIA,
«polypharmacy»
“Polypharmacy is associated with adverse
outcomes including mortality, falls, adverse drug
reactions, increased length of stay in hospital and
readmission to hospital soon after discharge”
Milton JC, Hill-Smith I, Jackson SHD. Prescribing for older people. BMJ. (2008)ADVERSE DRUG REACTIONS
“A response to a drug that is noxious and unintended
and occurs at doses normally used in man for the
prophylaxis, diagnosis or therapy of disease, or for
modification of physiological function.”
“React ions occurring as a result of error, misuse or
abuse, and to suspected react ions to medicines t hat are
unlicensed or being used off -label in addit ion to t he
aut horised use of a medicinal product in normal doses.”
World Health Organization. International drug monitoring: the role of national centres. WHO (1972)RISCHI DELLA IATROGENESI
Christel L Burgess, C D’Arcy J Holman and Anthony G Satti Med J Aust (2005)RISCHI DELLA IATROGENESI
Daniel S. Budnitz, Emergency Hospitalizations for Adverse Drug Events in Older Americans, N Engl J Med (2011)DEPRESCRIPTION
Deprescribing is the planned and supervised
process of dose reduct ion or stopping of
medicat ion that might be causing harm, or no
longer be of benefit.
Deprescribing is part of good prescribing –
backing off when doses are too high, or
stopping medications that are no longer
needed.
deprescribing.org/what-is-deprescribing/DEPRESCRIPTION
• Assess all medicat ions the patient is taking and
Step 1 indication for use
• Consider overall risk of medication related adverse
Step 2 effect s and benefit s of t reat ment
• Determine eligibility for medication to be
Step 3 discont inued
• Priorit ize medications for discontinuation
Step 4
• Implement and monitor medicat ion discont inuat ion
Step 5 planCRITERI DI BEERS
Comprendono i singoli farmaci o i gruppi di farmaci da
prescriversi, in generale, con la massima cautela perché
potenzialmente inappropriati e i farmaci la cui
prescrizione è potenzialmente inappropriata in specifiche
situazioni cliniche.
A. Farmaci di uso potenzialmente inappropriato
nell'anziano indipendentemente dalla diagnosi.
B. Farmaci di uso potenzialmente inappropriato
nell'anziano considerando la diagnosi.
American Geriatrics Society Beers Criteria® Update Expert Panel* (2019)CRITERI DI BEERS
Quality of
Therapeut ic Category, Drug(s) Rat ionale Recomm. St renght
Evidence
Insulin, sliding scale (insulin regimens Higher risk of hypoglycemia without Avoid Moderate Strong
containing only short- or rapid-acting improvement in hyperglycemia
insulin dosed according to current blood management regardless of care setting.
glucose levels without concurrent use Avoid insulin regimens that include only
of basal or long-acting insulin) short- or rapid- acting insulin dosed
according to current blood glucose levels
without concurrent use of basal or long-
acting insulin.
Sulfonylureas, long acting Avoid High Strong
Chlorpropamide Chlorpropamide: prolonged half-life in
older adults; can cause prolonged
hypoglycemia; causes SIADH
Glimepiride Glimepiride and glyburide: higher risk of
severe prolonged hypoglycemia in older
adults
Glyburide (aka glibenclamide)
American Geriatrics Society Beers Criteria® Update Expert Panel* (2019)START&STOPP
START
Screening Tool to Alert
doctors to Right Treatment
STOPP
Screening Tool of Older
Person's Prescriptions
Denis O'Mahony et. al STOPP/START criteria for potentially inappropriate prescribing in older people (2015)CONTENTS OF STOPP
Physiological System Num. of criteria
Cardiovascular system 17
Cent ral nervous system 13
Gast ro ‐intest inal system 5
Musculoskelet al system 8
Respiratory system 3
Urogenit al system 6
Endocrine system 4
Drugs t hat adversely affect fallers 5
Analgesics 3
Duplicate drug classes 1
Denis O'Mahony et. al STOPP/START criteria for potentially inappropriate prescribing in older people (2015)EFFECT OF STOPP ON THE
MEDICATION APPROPRIATENESS INDEX
Clinical Pharmacology & Therapeutics (2011)ANTIHYPERGLYCAEMICS IN
ELDERLY PATIENTS
Does your elderly (>65 y) patient with T2D meet one or more of the following
criteria:
• At risk of hypoglycemia (e.g. due to advancing age, tight glycemic control,
multiple comorbidities, drug interactions, hypoglycemia history or unawareness,
impaired renal function, or on sulfonylurea or insulin)
• Experiencing, or at risk of, adverse effects from antihyperglycemic
• Uncertainty of clinical benefit (frailty, dementia or limited life-expectancy)
YES NO
Cont inue
Antihyperglycemic(s)
Deprescribing.org (2019)YES Address potential contributors to
hypoglycemia (e.g. not eating,
drug interactions such as
trimethoprim/sulfamethoxazole
and sulfonylurea, recent cessation
Set individualized A1C and blood of drugs causing hyperglycemia)
glucose targets (otherwise
healthy with 10+ years life
expectancy, A1CREDUCE DOSE(S) OR STOP AGENT(S)
most likely to contribute to hypoglycemia (e.g. sulfonylurea, insulin; strong
recommendation from systematic review and GRADE approach) or other
adverse effects (good practice recommendation)
SWITCH TO AN AGENT
with lower risk of hypoglycemia (e.g. switch from glibenclamide to
gliclazide or non-sulfonylurea; change NPH or mixed insulin to detemir or
glargine insulin to reduce nocturnal hypoglycemia; strong recommendation
from systematic review and GRADE approach)
REDUCE DOSES
of renally eliminated antihyperglycemics (e.g. metformin, sitagliptin; good
practice recommendation) – See guideline for recommended dosing
Deprescribing.org (2019)ADA STANDARDS OF MEDICAL
CARE IN DIABETES (2019)
American Diabetes Association - Diabetes Care (2019)SENATOR PROJECT
European funded SENATOR consortium, coordinated by the Cork University (2018)SENATOR PROJECT
European funded SENATOR consortium, coordinated by the Cork University (2018)https://intercheckweb.marionegri.it/
Quando il decorso clinico di un
paziente anziano improvvisamente
peggiora il medico deve prima di tutto
chiedersi: «Che cosa ho fatto al
paziente?», invece di «Che cosa gli sta
facendo la malattia?».
Umberto Senin
Paziente Anziano, Paziente Geriatrico,
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