Reducing the Use of Inappropriate Medications Propoxyphene (Darvocet, etc.)

1
Reducing the Use of Inappropriate
MedicationsPropoxyphene (Darvocet,
etc.)Medications with Anticholinergic Effects

• Nursing Facility Inservice

2
Reducing the Use of Inappropriate Medications

• INSERT PHARMACY NAME is implementing new
  procedures to address the use of medications
  potentially inappropriate for use in the elderly
• Initial focus is on propoxyphene (e.g., Darvon,
  Darvocet, Wygesic) and medications with
  anticholinergic effects
• Goal is to reduce new orders for potentially
  inappropriate medications and increase monitoring
  for adverse effects where suitable alternatives
  are not available
• This should result in improved patient care and
  documentation required for survey process

3
Propoxyphene Product Alert(Darvon, Darvocet N,
Darvocet A 500, Wygesic)

• Propoxyphene is inappropriate for use in elderly
  patients due to its adverse effects and
  questionable efficacy
• Studies have demonstrated that propoxyphene is no
  more effective than acetaminophen (Tylenol) or
  aspirin in reducing pain, and in most studies was
  less effective

4
Propoxyphene (Darvon, etc.) vs Aspirin or
Acetaminophen
Propoxyphene Questionable Efficacy
ASA or acetaminophen more effective than
propoxyphene 7 studies
ASA or acetaminophen equal to propoxyphene 1
study
ASA or acetaminophen less effective than
propoxyphene No studies
5
Estimated Cost of a Single Week of q4h Therapy
6.59
Propoxyphene More Costly
5.07
4.62
4.44
3.06
1.00
0.42
Generic Darvocet N
Darvon Compound
Darvon
Aspirin
Wygesic
Darvocet-N
Acetaminophen
6
What makes propoxyphene inappropriate for elderly
patients?

• CNS Side Effects
• Dizziness, Sedation, Drowsiness, Confusion
• May increase risk for falls
• Research has identified propoxyphene use as a
  risk factor for hip fractures
• Other Adverse Effects
• Poor appetite
• Nausea, vomiting
• Trouble urinating or emptying bladder
• Constipation

7
What makes propoxyphene inappropriate for elderly
patients?

• Active metabolite has cardiotoxic, arrhythmic
  effects, and CNS toxicities
• Active metabolite has long elimination half-life
  of 30-36 hours, which poses high risk of
  accumulation if given repeatedly
• Older adults are especially prone to increased
  serum concentrations or reduced elimination of
  propoxyphene
• Note There is a 50 decline in renal (kidney)
  clearance of medications in people age 75 and
  older

8
Propoxyphene and RAPs

• Propoxyphene may cause, aggravate, or contribute
  to the following RAP problems due to its adverse
  effects
• 1. Delirium
• 2. Cognitive Loss/Dementia
• 3. Visual Function
• 4. Communication
• 5. ADLs
• 6. Urinary Incontinence
• 8. Mood State
• 9. Behavioral Symptoms
• 11. Falls
• 15. Dental Care

9
Alternatives to Propoxyphenefor Episodic
(non-continuous) Pain

• Mild to Moderate Pain
• Acetaminophen is drug of choice
• Pain not controlled by acetaminophen is unlikely
  to be controlled by propoxyphene
• Traditional NSAIDs should be avoided in patients
  who require long-term daily analgesic therapy
• Moderate to Severe Pain
• Hydrocodone (Vicodin) prn

10
Propoxyphene AlertPharmacy Procedures

• Propoxyphene Alert Letter
• Sent to prescribers for all new propoxyphene
  orders with recommendation for alternative
  therapy
• Propoxyphene Alert Card (see example)
• Sent by pharmacy for all propoxyphene refills
• Punch hole in card and place in front of
  patients MAR
• Contact your Consultant Pharmacist for any
  questions

11
What You Can Do

• Mild or moderate pain
• Do not encourage or recommend propoxyphene
• Episodic pain Acetaminophen 650mg po q4h prn
  pain.
• Continuous pain Acetaminophen 650mg po q4h. Do
  not exceed 4000mg per day.
• Moderate to severe pain not controlled by
  acetaminophen
• Episodic pain Hydrocodone prn
• Continuous pain Hydrocodone
• A prophylactic bowel regimen should be initiated
  with the commencement of persistent opioid
  therapy
• For patients receiving propoxyphene
• Monitor for adverse effects and document if
  observed
• Report adverse effects to prescriber

12
Pain Management

• For chronic, severe, or uncontrolled pain,
  contact your Consultant Pharmacist for therapy
  recommendations

13
Anticholinergic Alert

• Many medications are potentially inappropriate
  for use in elderly patients due to their
  anticholinergic effects
• For some of these medications, there are no
  suitable alternatives
• Anticholinergic side effects are among the most
  common drug-related effects experienced by
  elderly nursing facility residents
• It is important to know commonly used medications
  with anticholinergic effects
• Anticholinergic adverse effects may be more
  likely or severe if the patient is receiving
  several medications with anticholinergic effects
• Observe patient for adverse effects so problems
  can be avoided, managed, or reversed

14
Symptoms of Anticholinergic Effects

• Dry or sticky lips difficulty beginning to speak
  (need to lick lips first)
• Urinary disorders, necessitating use of catheter
• Dry, pale, cool skin
• Insecure movement falls without obvious reason
• Blurred vision
• Increased anxiety, with rapid shallow breathing,
  tachycardia (rapid heart rate), cardiac
  arrhythmias
• Drowsiness, sedation
• Fatigue, weakness
• Constipation
• Memory impairment, confusion, disorientation
• Hallucinations, delirium

15
Spectrum of Anticholinergic Side Effects
16
Anticholinergics and RAPs

• Medications with anticholinergic effects may
  cause, aggravate, or contribute to the following
  RAP problems due to adverse effects
• 1. Delirium
• 2. Cognitive loss/Dementia
• 3. Visual Function
• 4. Communication
• 5. ADLs
• 6. Urinary Incontinence
• 8. Mood State
• 9. Behavioral Symptoms
• 11.Falls
• 15.Dental Care

17
Medications with Anticholinergic Effects
18
Anticholinergic AlertPharmacy Procedures

• Direct communication with prescriber
  recommendation for safer alternative
• Anticholinergic Alert Form (see example)
• Completed by Consultant Pharmacist as part of
  drug regimen review for new orders
• Indicates all medications with anticholinergic
  effects that patient is receiving
• Anticholinergic Alert Card (see example)
• Sent by pharmacy with all refills for medications
  with anticholinergic effects
• Punch hole in card and place in front of
  patients MAR
• Contact your Consultant Pharmacist for any
  questions

19
What You Can Do

• Become familiar with symptoms of anticholinergic
  effects and the medications that cause them
• Note when patient is receiving more than one
  medication with anticholinergic effects
• Monitor for adverse effects and document if
  observed
• Resist temptation to request additional
  medication to treat symptoms of anticholinergic
  effects
• Contact Consultant Pharmacist to resolve
  medication-related problems