Savvy Psychopharmacology

Polypharmacy in older adults

Current Psychiatry. 2020 April;19(4):40-46

References

1. Masnoon N, Shakib S, Kalisch-Ellett, et al. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17:230.
2. Kantor ED, Rehm CD, Haas JS, et al. Trends in prescription drug use among adults in the United States from 1999-2012. JAMA. 2015;314(17):1818-1831.
3. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57-65.
4. Maiese DR. Healthy People 2010-leading health indicators for women. Womens Health Issues. 2002;12(4):155-164.
5. National Academy of Sciences. Institute of Medicine (US) Roundtable on Health Literacy. The Safe Use Initiative and Health Literacy: workshop summary. https://www.ncbi.nlm.nih.gov/books/NBK209756/. Published 2010. Accessed January 22, 2020.
6. Caranasos GJ, Stewart RB, Cluff LE. Drug-induced illness leading to hospitalisation. JAMA. 1974;228(6):713-717.
7. Agbabiaka T. Prevalence of drug–herb and drug-supplement interactions in older adults: a cross-sectional survey. Br J Gen Pract. 2018;68(675):e711-e717. doi: 10.3399/bjgp18X699101.
8. Agbabiaka T, Wider B, Watson L, et al. Concurrent use of prescription drugs and herbal medicinal products in older adults: a systematic review. Drugs Aging. 2017;34(12):891-905.
9. de Souza Silva JE, Santos Souza CA, da Silva TB, et al. Use of herbal medicines by elderly patients: a systematic review. Arch Gerontol Geriatr. 2014;59(2):227-233.
10. Gahche J, Bailey RL, Potischman N, et al. Dietary supplement use was very high among older adults in the United States in 2011-2014. J Nutr. 2017;147(10):1968-1976.
11. Nisly NL, Gryzlak BM, Zimmerman MB et al. Dietary supplement polypharmacy: an unrecognized public health problem? Evid Based Complement Alternat Med. 2010;7(1):107-113.
12. Kennedy J, Wang CC, Wu CH. Patient disclosure about herb and supplement use among adults in the US. Evid Based Complement Alternat Med. 2008;5(4):451-456.
13. Dickinson A. History and overview of DSHEA. Fitoterapia. 2011;82(1):5-10.
14. Dietary Supplement Health and Education Act of 1994. Public Law 103-417,103rd Congress. https://www.congress.gov/bill/103rd-congress/senate-bill/784. Accessed February 20, 2020.
15. US Department of Health & Human Services. National Institute on Aging. Dietary supplements. https://www.nia.nih.gov/health/dietary-supplements. Reviewed November 30, 2017. Accessed January 22, 2020.
16. Ragheb M. The clinical significance of lithium-nonsteroidal. J Clin Psychopharmacol. 1990;10(5):350-354.
17. 2019 American Geriatrics Society Beers Criteria^® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria^® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694.
18. Cho H, Myung J, Suh HS, et al. Antihistamine use and the risk of injurious falls or fracture in elderly patients: a systematic review and meta-analysis. Osteoporos Int. 2018;29(10):2163-2170.
19. Manlucu J, Tonelli M, Ray JG, et al. Dose-reducing H2 receptor antagonists in the presence of low glomerular filtration rate: a systematic review of the evidence. Nephrol Dial Transplant. 2005;20(11):2376-2384.
20. Sudafed [package insert]. Fort Washington, PA: McNeil Consumer Healthcare Division; 2018.
21. US National Library of Medicine. National Center for Biotechnology Information. PubChem Compound Summary: Dextromethorphan; CID=5360696. https://pubchem.ncbi.nlm.nih.gov/compound/5360696. Accessed January 22, 2020.
22. Hedya SA, Swoboda HD. Lithium toxicity. https://www.ncbi.nlm.nih.gov/books/NBK499992/. Updated August 14, 2019. Accessed January 22, 2020.
23. US Department of Health & Human Services. National Center for Complementary and Integrative Health. Herb-drug interactions: what the science says. https://www.nccih.nih.gov/health/providers/digest/herb-drug-interactions-science. Published September 2015. Accessed January 22, 2020.
24. Shader RI, Greenblatt DJ. Bees, ginseng and MAOIs revisited. J Clin Psychopharmacol. 1988;8(4):235.
25. Chua YT. Interaction between warfarin and Chinese herbal medicines. Singapore Med J. 2015;56(1):11-18.
26. Bonetto N, Santelli L, Battistin L, et al. Serotonin syndrome and rhabdomyolysis induced by concomitant use of triptans, fluoxetine and hypericum. Cephalalgia. 2007;27(12):1421-1423.
27. Henderson L, Yue QY, Bergquist C, et al. St John’s wort (Hypericum perforatum): drug interactions and clinical outcomes. Br J Clin Pharmacol. 2002;54(4):349-356.
28. Johne A, Schmider J, Brockmöller J, et al. Decreased plasma levels of amitriptyline and its metabolites on comedication with an extract from St John’s wort (Hypericum perforatum). J Clin Psychopharmacol. 2002;22(1):46-54.
29. Eich-Höchli D, Oppliger R, Golay KP, et al. Methadone maintenance treatment and St John’s wort: a case report. Pharmacopsychiatry. 2003;36(1):35-37.
30. Johne A, Brockmöller J, Bauer S, et al. Pharmacokinetic interaction of digoxin with an herbal extract from St John’s wort (Hypericum perforatum). Clin Pharmacol Ther. 1999;66(4):338-345.
31. Andrén L, Andreasson A, Eggertsen R. Interaction between a commercially available St John’s wort product (Movina) and atorvastatin in patients with hypercholesterolemia. Eur J Clin Pharmacol. 2007;63(10):913-916.
32. Van Strater AC. Interaction of St John’s wort (Hypericum perforatum) with clozapine. Int Clin Psychopharmacol. 2012;27(2):121-124.
33. Nöldner M, Chatterjee SS. Inhibition of haloperidol-induced catalepsy in rats by root extracts from Piper methysticum F. Phytomedicine. 1999;6(4):285-286.
34. Boerner RJ, Klement S. Attenuation of neuroleptic-induced extrapyramidal side effects by kava special extract WS 1490. Wien Med Wochenschr. 2004;154(21-22):508-510.
35. Schelosky L, Raffauf C, Jendroska K, et al. Kava and dopamine antagonism. J Neurol Neurosurg Psychiatry. 1995;58(5):639-640.
36. Singh YN. Potential for interaction of kava and St. John’s wort with drugs. J Ethnopharmacol. 2005;100(1-2):108-113.
37. Patel NM, Derkits R. Possible increase in liver enzymes secondary to atorvastatin and black cohosh administration. J Pharm Prac. 2007;20(4):341-346.
38. Rockwell S, Liu Y, Higgins SA. Alteration of the effects of cancer therapy agents on breast cancer cells by the herbal medicine black cohosh. Breast Cancer Res Treat. 2005;90(3):233-239.
39. Granger AS. Ginkgo biloba precipitating epileptic seizures. Age Ageing. 2001;30(6):523-525.
40. Mohutsky MA, Anderson GD, Miller JW, et al. Ginkgo biloba: evaluation of CYP2C9 drug interactions in vitro and in vivo. Am J Ther. 2006;13(1):24-31.
41. Zhang XY, Zhou DF, Zhang PY, et al. A double-blind, placebo controlled trial of extract of Ginkgo biloba added to haloperidol in treatment-resistant patients with schizophrenia. J Clin Psychiatry. 2001;62(11):878-883.
42. Atmaca M, Tezcan E, Kuloglu M, et al. The effect of extract of ginkgo biloba addition to olanzapine on therapeutic effect and antioxidant enzyme levels in patients with schizophrenia. Psychiatry Clin Neurosci. 2005;59(6):652-656.
43. Doruk A, Uzun O, Ozsahin A. A placebo-controlled study of extract of ginkgo biloba added to clozapine in patients with treatment-resistant schizophrenia. Int Clin Psychopharmacol. 2008;23(4):223-237.
44. Vaes LP. Interactions of warfarin with garlic, ginger, ginkgo, or ginseng: nature of the evidence. Ann Pharmacother. 2000;34(12):1478-1482.
45. Kanji S, Seely D, Yazdi F, et al. Interactions of commonly used dietary supplements with cardiovascular drugs: a systematic review. Syst Rev. 2012;1:26.
46. Wallace JL. Pathogenesis of NSAID-induced gastroduodenal mucosal injury. Best Pract Res Clin Gastroenterol. 2001;15(5):691-703.
47. Triadafilopoulos G, Sharma R. Features of symptomatic gastroesophageal reflux disease in elderly patients. Am J Gastroenterol. 1997;92(11):2007-2011.
48. Haastrup PF, Thompson W, Søndergaard J, et al. Side effects of long-term proton pump inhibitor use: a review. Basic Clin Pharmacol Toxicol. 2018;123(2):114-121.
49. Diamond BJ, Bailey MR. Ginkgo biloba: indications, mechanisms and safety. Psychiatr Clin N Am. 2013;36:73-83.
50. White CM. The pharmacology, pharmacokinetics, efficacy, and adverse events associated with kava. J Clin Pharmacol. 2018;58(11):1396-1405.
51. Gleitz J, Beile A, Peters T. (+/-)-Kavain inhibits veratridine-activated voltage-dependent Na(+)-channels in synaptosomes prepared from rat cerebral cortex. Neuropharmacology. 1995;34(9):1133-1138.
52. Kahrilas PJ. Gastroesophageal reflux disease and its complications. In: Feldman M, ed. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 6th ed. Philadelphia, PA: WB Saunders Company; 1998:498-516.
53. Haenisch B, von Holt K, Wiese B, et al. Risk of dementia in elderly patients with the use of proton pump inhibitors. Eur Arch Psychiatry Clin Neurosci. 2015;265(5):419-428.
54. Sheen E, Triadafilopoulos G. Adverse effects of long-term proton pump inhibitor therapy. Dig Dis Sci. 2011;56(4):931-950.
55. Pitkälä KH, Suominen MH, Bell JS, et al. Herbal medications and other dietary supplements. A clinical review for physicians caring for older people. Ann Medicine. 2016;48(8):586-602.
56. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum. 2000;43(9):1905-1915.
57. Vandvik PO, Lincoff AM, Core JM, et al. Primary and secondary prevention of cardiovascular disease: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e637S-e668S. doi: 10.1378/chest.11-2306.

CASE CONTINUED

Mrs. B is diagnosed with lithium toxicity due to a drug–drug interaction with naproxen. Her lithium is held, and IV fluids are administered. Her symptoms resolve over the next few days. Mrs. B and her son are taught about the interaction between lithium and NSAIDs, and she is counseled to avoid all OTC NSAIDs other than aspirin. Her clinician recommends taking acetaminophen because it will not interact with her medications and is the recommended OTC treatment for mild or moderate pain in geriatric patients.^17,56

Next, the clinician addresses Mrs. B’s GERD. Although Mrs. B had been taking PPIs twice daily, her physician recommends decreasing the omeprazole frequency to once daily to minimize adverse effects and pill burden. She also decreases Mrs. B’s aspirin from 325 to 81 mg/d because evidence suggests that when used to prevent CAD, lower-dose aspirin is effective as high-dose aspirin and has fewer adverse effects.⁵⁷ Finally, she advises Mrs. B to stop taking ginkgo biloba and kava kava and to always check with her primary care physician or pharmacist before beginning any new medication, dietary supplement, or vitamin.

Mrs. B agrees to first check with her clinicians before following advice from mass media. A follow-up appointment is scheduled for 2 weeks to assess renal function, a lithium serum concentration, and adherence to her simplified medication regimen.

Related Resources

US Department of Health and Human Services. National Institutes of Health. MedlinePlus. Herbs and supplements. https://medlineplus.gov/druginfo/herb_All.html.
US Department of Health and Human Services. National Center for Complementary and Integrative Health. https://nccih.nih.gov/.

Drug Brand Names

Atorvastatin • Lipitor
Atropine • Atropen
Benztropine • Cogentin
Clozapine • Clozaril
Clopidogrel • Plavix
Colchicine • Colcrys, Gloperba
Digoxin • Cardoxin, Digitek
Lidocaine • Lidoderm, Xylocaine Viscous
Lithium • Eskalith, Lithobid
Methadone • Methadose
Morphine • Kadian, Morphabond
Paroxetine • Paxil
Trazodone • Desyrel
Warfarin • Coumadin, Jantoven

Polypharmacy in older adults

References

CASE CONTINUED

Related Resources

Drug Brand Names

Pages

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