Practice Experts: CNS-active drug polypharmacy in patients with dementia

Although psychotropic medications are often prescribed in community-dwelling persons with dementia for management of behavioural and psychological symptoms (e.g., delusions, agitation, apathy), there is limited evidence for the use of these medications in this population. The Beers Criteria from the American Geriatrics Society advise against central nervous system (CNS)-active polypharmacy (i.e., combinations of multiple psychotropic and/or opioid medications) due to increased risk of falls; as well, psychotropics can cause impaired cognition, cardiac conduction abnormalities and respiratory suppression when opioids are prescribed. A recent study determined The prevalence of polypharmacy with CNS-active medications among community-dwelling older adults with dementia. The researchers examined Medicare claims data from 2018 for more than 1.1 million older adults with dementia. CNS-active polypharmacy (defined as exposure to 3 or more medications for longer than 30 days from 6 drug classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics [i.e., “z-drugs”], opioids) was found to occur in almost one in seven (13.9%) elderly patients. In this cohort, 57.8% had been prescribed these drugs for at least six months, and 6.8% for one year. Antidepressants were the most commonly prescribed drug class, followed by antiepileptics (likely used for treating pain) and antipsychotic drugs. The most common medications were gabapentin, trazodone and quetiapine. Implications for pharmacists Almost 14% of older community-dwelling adults with dementia had long-term prescriptions for three or more CNS-active drugs. Although the researchers were unable to assess the appropriateness of the particular combinations, they cautioned that there is evidence to indicate that there is an increased risk of adverse effects. Pharmacists can work with families and healthcare providers to help refine a patient’s medications. For example, in some cases, symptoms that had initially triggered the prescription may have waned. Reference: Maust DT, Strominger J, Kim MH, et al. Prevalence of central nervous system-active polypharmacy among older adults with dementia in the US. JAMA 2021;325:952-61. Triptan overuse and nonpersistence Migraine is a common neurologic disorder that affects about 12% of the population. Triptans are highly effective for acute migraine and are considered first-line treatments in patients not adequately managed by nonsteroidal anti-inflammatory drugs or acetaminophen. Clinical guidelines suggest trials of at least three different triptans before a patient is considered triptan-resistant. A register-based cohort study conducted in Denmark published findings on trends in triptan use over a 25-year period. The healthcare system in Denmark is associated with low medication costs. During the study period, a total of 381,695 patients purchased triptans at least one time. Approximately one in five triptan purchasers every year was male; this ratio did not change over the study period. Over the 25-year study period, the yearly prevalence of triptan use increased from 5.2 to 14.5 per 1,000 inhabitants. Between the years of 2014 and 2019, 12.3% of Danish residents bought a triptan. After the initial purchase, 43% of first-time buyers did not buy another triptan for five years. As well, in contrast to guidelines, 90% of patients who discontinued triptan use had tried only one triptan type. Triptan overuse, defined as triptan use on more than at least 10 days a month for three consecutive months, was observed in 56 of every 1,000 triptan users or a yearly prevalence of 0.8%. Implications for pharmacists Low rates of persistence with triptans were observed in this study, likely due to poor efficacy and/or unpleasant side effects rather than economic concerns. Rather than abandoning the entire triptan class in a patient who experiences poor results or adverse effects with one triptan, it may be helpful to switch to a different triptan. This study also confirmed that triptan overuse is not uncommon. Pharmacists can take an active role in warning patients about the risk of triptan overuse, and promote the use of headache diaries to monitor headache frequency as well as medication use. Sandra Knowles, BScPhm, is a drug information pharmacist with Sunnybrook Health Sciences Centre in Toronto. References: Davidsson OB, Olofsson IA, Kogelman LJ, et al. Twenty-five years of triptans: a nationwide population study. Cephalalgia 2021;41:894-904. Gonzalez-Oria C, Belvis R, Cuadrado ML, et al. Document of revision and updating of medication overuse headache (MOH). Neurologia 2021;36:229-40. https://www.elsevier.es/en-revista-neurologia-english-edition--495-articulo-document-revision-updating-medication-overuse-S2173580821000249 (accessed April 12, 2021).