T2DM and multi‐morbidity Polypharmacy Prof. Johan Wens, MD, PhD University of Antwerp Dpt. Primary and Interdisciplinary Care
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T2DM and multi‐morbidityPolypharmacy
Prof. Johan Wens, MD, PhD
University of AntwerpDpt. Primary and Interdisciplinary Care
Multi‐morbidity in primary care
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Adapted: Fortin, Stewart et al; Ann Fam Med 2012 Mar;10(2):142‐51.
Barnett, K, Mercer SW, Norbury M, Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross‐sectional study. Lancet, 2012; 380(9836):37‐43.
Barnett, K, Mercer SW, Norbury M, Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross‐sectional study. Lancet, 2012; 380(9836):37‐43.
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Barnett, K, Mercer SW, Norbury M, Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross‐sectional study. Lancet, 2012; 380(9836):37‐43.
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Teljeur C, Smith SM, Paul G, Kelly A, O'Dowd T. Multimorbidity in a cohort of patients with type 2 diabetes. Eur J Gen Pract. 2013 Mar;19(1):17‐22. doi: 10.3109/13814788.2012.714768.
Network diagram of most common chronic condition pairs in cohort T2DM
Fig 1 Proportion of people with three index conditions who have each of other conditions.
Dumbreck S, Flynn A, Nairn, M, et al. Drug‐disease and drug‐drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h949
A case study…
Mrs. A78 year‐old
T2DMprevious MI (still smokes…)osteo‐arthritisCOPDdepression
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Hughes, L. D., et al. (2013). "Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity." Age Ageing 42(1): 62‐69.
A case study…
Following guidelines:‐ advised 9 self‐care/lifestyle alterations
with others recommended under circumstances
‐ expected to attend 4 ‐ 6 routine GP appointmentsand 8 – 30 psychosocial intervention appointments for depression, smoking cessation, pulmonary rehabilitation
‐ prescribed 11 medications as a minimum‐ 10 other drugs routinely recommended
depending on intermediate outcome control, symptoms and progression of disease
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Hughes, L. D., et al. (2013). "Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity." Age Ageing 42(1): 62‐69.
A case study…
Following guidelines:‐ advised 9 self‐care/lifestyle alterations
with others recommended under circumstances
‐ expected to attend 4 ‐ 6 routine GP appointmentsand 8 – 30 psychosocial intervention appointments for depression, smoking cessation, pulmonary rehabilitation
‐ prescribed 11 medications as a minimum‐ 10 other drugs routinely recommended
depending on intermediate outcome control, symptoms and progression of disease
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Hughes, L. D., et al. (2013). "Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity." Age Ageing 42(1): 62‐69.
Fig 2 Potentially serious drug-drug interactions between drugs recommended by clinical guidelines for three index conditions and drugs recommended by each of other 11 other
guidelines.
Dumbreck S, Flynn A, Nairn, M, et al. Drug‐disease and drug‐drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h949
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Dumbreck S, Flynn A, Nairn, M, et al. Drug‐disease and drug‐drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h949
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Fig 3 Types of potentially serious harm from drug-drug interactions between drugs recommended by clinical guidelines for three index conditions and drugs recommended by
each of other 11 other guidelines.
Dumbreck S, Flynn A, Nairn, M, et al. Drug‐disease and drug‐drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h949
Medicine management
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Payne RA, Avery AJ, Duerden M, Saunders CL, Simpson CR, Abel GA. Prevalence of polypharmacy in a Scottish primary care population. Eur J Clin Pharmacol 2014;70:575‐81.
% 4 to 10 medications > 10 medications
overall adults 16,9 4,6
age 60 – 70 28,6 7,4
age ≥ 80 years 51,8 18,6
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Payne RA, Avery AJ, Duerden M, Saunders CL, Simpson CR, Abel GA. Prevalence of polypharmacy in a Scottish primary care population. Eur J Clin Pharmacol2014;70:575‐81.
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Payne RA, Avery AJ, Duerden M, Saunders CL, Simpson CR, Abel GA. Prevalence of polypharmacy in a Scottish primary care population. Eur J Clin Pharmacol2014;70:575‐81.
What can we do…?
‐ medication review
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What can we do…?
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O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015 Mar;44(2):213‐8. doi: 10.1093/ageing/afu145. Epub 2014 Oct 16.
What can we do…?
‐ medication review‐ from EBM guidelines to “personal management”‐ prioritization
clinical judgementengagement with patient preferences
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Conclusions
‐ Potentially serious drug‐drug interactions are common‐ Drug‐disease interactions are less common
exception: chronic kidney disease‐ Future guidelines need‐ epidemiological knowledge of index disease + most
common comorbidities (attention CKD)‐ systematic approach regarding potential interactions
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Thank you
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