Dr. Dee Mangin, Professor of Family Medicine and the Associate Chair and Director, Research, at McMaster University, will join practicing pharmacist, and Vice President, Pharmacy Affairs, Sandra Hanna of the Neighbourhood Pharmacy Association of Canada to discuss medication risks, deprescribing and the dangers of polypharmacy in this one hour webinar. Learn more at www.asklistentalk.ca

2. Our Host and Moderator
Jignesh Padia
Certified Manager of Operational
Excellence from American Society of
Quality, member on a local patient
safety advisory committee with Regina
Qu’Appelle Health Region, and
member of Patients for Patient Safety
Canada (PFPSC)
Christopher Thrall
Communications Officer at
Canadian Patient Safety
Institute (CPSI)

3. Sponsors for CPSW
Thank you for your support!

4. Today’s Guest Speakers
Dr. Dee Mangin
Professor of Family Medicine and
the Associate Chair and Director
of Research, and David Braley &
Nancy Gordon Chair in Family
Medicine at McMaster University
Sandra Hanna
Practicing pharmacist and Vice
President of Pharmacy Affairs at
Neighbourhood Pharmacy
Association of Canada and Chief
Innovation Officer at Gold Links
Health Solutions

5. @McMasterFamMed
Not All Medicines Get Along
Dee Mangin
David Braley Chair in Family Medicine
@DeeMangin

6. “This copy is provided exclusively for research purposes and private
study. Any use of the copy for a purpose other than research or
private study may require the authorization of the copyright owner of
the work in question. Responsibility regarding questions of copyright
that may arise in the use of this copy is assumed by the recipient.”

7. Disclosure
• Relationships with commercial interests:
– Grants/Research Support: Public funding only
CIHR, NIHR, NHS, Labarge Optimal Aging Fund, Ontario Health Services Research Fund
– Speakers Bureau/Honoraria: Nil
– Consulting Fees: Nil
– Other: I have provided expert witness reports for the plaintiff in class action legal cases
taken against pharmaceutical companies. Any fees are donated to an independent patient
drug side effect information and reporting website RxISK.org

11. The Invisible Pandemic

12. Canada: Adverse drug effects requiring medical care 13% of
those on ≥ 5 medications (>1/3 of our senior patients)

13. Specific Problems
Morbidity
falls, balance and strength,
cognition and memory problems,
sleep, nutrition, fatigue……

14. 70-year-old Woman
• COPD
• Diabetes
• High blood pressure
• Arthritis
• Osteoporosis
Boyd C et al JAMA 2005

15. Guideline Based Disease Treatment
• 19 doses of 12 different medications
• Taken at five times during the day
• 14 non pharmacological activities
10 16 different possibilities for significant medicine
interactions either with other medicines or other diseases
Mangin D in: Prescribing for Women in Primary Care

16. Illness Disease
Ursus Wehrli

17. Leaping into the void

18. Metaphors and Talking Points
Metaphors for treatment burden and the need for individualized
tailoring
1) the way older bodies respond to disease or risk factors and
process medications changes
– different targets
– lower medication doses to avoid side effects while achieving the same
benefit
2) the evidence for medication effectiveness is weaker, and
sometimes absent (esp in the multi-morbid and frail)
3) adverse effects from medication burden are additive
4) the goals of treatment may change as the end of life comes
closerFarrell B. and Mangin D. Am Fam Physician 2018 in press

19. • Review the medications of all
older adults with an eye to
deprescribing, particularly those
who are vulnerable to the
adverse effects of medication
• Consider each medication for
potential withdrawal, extending
beyond standardized lists

20. A life worth living
“Not least do people differ in their attitude to life.
Some cling to it as a miser to his money, and to as little purpose.
Others wear it lightly-ready to risk it for a cause, a hope, a song, the
wind on their face.
When so many people think of it as a means, the doctor, surely, would
be wrong to insist that it is always the first of ends.
Life is not really the most important thing in life.”
Theodore Fox
The Purpose of Medicine
Lancet 1965

21. Decisions in older complex patients should routinely consider
expected survival and quality of life, giving the highest priority
to patient/family preferences
Before initiating a potentially ‘appropriate’ medication,
consider the validity of the evidence IN THIS PATIENT based
on patient characteristics and preferences

22. Employ mixed implicit and explicit approaches
Elderly people have different priorities from the
epidemiological ones of health professionals
Professionals relying on epidemiological
knowledge to guide their enquiries about unmet
needs in older patients may find that the needs
that they identify are not perceived as unmet and
that this focus is perceived as intrusive by patients
Drennan V et al Fam. Pract. 24:454-460, 2007

23. Implicit approaches take into consideration research data on
potentially inappropriate medicines, effectiveness and safety
and also consider clinical circumstances, and patient/family
preferences.
Implicit approaches are less algorithmic and require more
time, knowledge, and judgment.
This more complex approach is better suited to multimorbidity
and to a shared decision-making model.

24. What Matters to You?
• What are the things you’d like to be able to do that your
health stops you?
• Which symptoms do you most want your treatments to help
with?
• What don’t you want treatment for?
• How important to you are treatments that try to prevent
future illnesses versus ones that treat your current
symptoms?
– Use cholesterol drug example
– Use red pill / blue pill example and rate out of 10

25. What Matters to You?
• Which medicine(s) do you want to stop the most?
• Which do you really want to keep taking?
• Do you take any medicines in ways that are more helpful
than the instructions?

26. Taming the monsters in your office practice

27. How to start in your office practice
• Choose a side effect or “burden”
– Focus on one particular side effect burden across all medications
(e.g. additive anticholinergic effects, serotonergic burden
hypotension burden)
– Focus on reversing a prescribing cascade (NSAID and
hypertension…..others?)

28. Examples of problematic cumulative ‘burdens’
• Serotonin burden
• Anticholinergic burden
• QT prolonging meds (think ABs)
• Pro-hemorrhagic drugs
• Hypotensive drugs

29. • Choose a problem
– Ask yourself as a routine first question “Is this problem caused by
a drug(s)?” (e.g. falls or cognitive impairment)
How to start in your office practice

30. • Look at ‘legacy prescribing’ – medications started for
usually an intermediate duration but continued indefinitely
(e.g. PPIs, SSRIs, bisphosphonates, benzodiazepines)
– can your prescribing system be modified to flag when the course
of intended treatment is complete?
– Could you modify the initial discussion to set expectations when
starting?
– Other ideas?
How to start in your office practice

31. Legacy Drugs
Antidepressants 46%
Bisphosphonates 14%
PPIs 45%
Current prescription >60%
Mangin D, Lawson J, Cuppage J et al Annals of Family Medicine Nov 2018

32. • Look at ‘legacy prescribing’ (e.g. PPIs, SSRIs,
bisphosphonates, benzodiazepines)
– how can you modify your approach to prescribing system to flag
when the course of intended treatment is complete?
– Could you modify the initial discussion to set expectations when
starting?
– Other ideas?
How to start in your office practice

33. • Choose specific medications to focus on
– for example, target medications known to have significant
changes in metabolism/excretion or effects or a shift in evidence
in the elderly (e.g. beta blockers)
How to start in your office practice

34. • Choose 1-2 patients/day with whom to start deprescribing
conversations.
How to start in your office practice

35. • “Pause and Monitor” – frame as a drug holiday
• Taper as a rule – stopping medicines is a gentle art
• Discuss anticipated withdrawal effects: reassure/red flag
• Discuss monitoring (who what how often)
• Discuss criteria for restarting
Tapering

36. When patients have multimorbidity, the single
disease model (and its incentivisation) should
be spurned.

38. • Quality measures and funding need to value “not doing” to
incentivise review processes aimed at reducing treatment
burden as a routine preventive activity
• Medical training should include generalist approaches to
polypharmacy and multimorbidity, including prioritisation
skills and approaches to stopping medicines
Policy implications

39. The Vision
TAPER
A systematic approach to reducing the
burden of polypharmacy for routine
prevention in older adults

40. Polypharmacy carries significant
morbidity and morality as well as
treatment burden
Most patients would be happy to have
a conversation about reducing
polypharmacy

42. Department of Family Medicine
Michael G. DeGroote School of Medicine
Faculty of Health Sciences
fammedmcmaster.ca
@McMasterFamMed
Contact:
mangind@mcmaster.ca
@DeeMangin

44. National Group Purchasing Organization

45. Fit‐for‐Purpose Products

46. The Right Product for the Right Purpose

53. Zopiclone
3.75 mg
tablets
Colchicine
0.6 mg unit
dose
Heparin
5,000
units/0.5
mL PFS
Gefitinib
250 mg
unit dose
tablets
Fit‐for‐Purpose Products
Now Commercially Available

54. Making the System Safer.
Freeing Hospital Resources for Higher Value
Tasks.

55. www.healthprocanada.com/transformingtogether

56. Not all meds get along.
Leveraging inter-professional
collaboration to best serve our
patients

57. Neighbourhood Pharmacy
Association of Canada
We represent the leading pharmacy brands in Canada and have demonstrated a history of strategic leadership
and collaborative problem solving. We are the respected voice and advocate for the business of pharmacy and
its vital role in sustaining the accessibility, quality and affordability of patient care for Canadians. Our goal is to
achieve a sustainable pharmacy future by bringing strategic initiatives forward, forming effective alliances, and
improving Canada’s pharmacy environment.
Our membership encompasses the retail, long-term care, and specialty care settings.
Contacts:
Sandra Hanna, Vice President Pharmacy Affairs
O: 416. 226.9100 ext. 4004
M: 416. 543.5508
shanna@neighbourhoodpharmacies.ca
57Neighbourhood Pharmacy Association of Canada

58. What are we really concerned
about?
58
• Drug – Drug Interactions
• Prescription Drugs
• Natural Health Products
• Vitamins / Supplements
• Over-the-counter Products
• Alcohol & other substance use
• Drug – Disease Interactions
• Non-Adherence or Non-Persistence
• Diversion

59. Some sobering facts
59
• Up to 25% of hospitalizations are drug-related
• Adverse Drug Reactions have been estimated to account for up to
two-thirds of drug-related hospital admissions and ED visits
• Non-adherence
• 50% of patients are non-adherent to their medications
• 1 in 3 initial prescriptions not filled
It’s not enough to manage a patient’s conditions – we have to ensure
that we are appropriately managing their medications!

60. Pharmacy – a
vital partner
in the
delivery of
accessible
patient care
60
Primary Care
Drug optimization;
Med Management
Public Health &
Harm Reduction

62. 62
Circle of
Care
Physician
Family /
Caregiver
Allied
Health
Pharmacy
Friends /
Google
Home
Care
Hospital

63. Pharmacy Services
• “Dispensing”
• Medication Management & Care Plans
• Prescription & OTC
• Prescribing
• Renewing chronic prescriptions
• Initiating prescriptions
• Adapting Prescriptions
• Immunization & Vaccine Administration

64. 64
Pharmacy
Services

65. Best Possible Medication History
• Patients should maintain up-to-date medication lists (BPMH) at
all times
• Above & beyond patients’ medication profile & health record
• Service offered by all pharmacies
• Annual
• Follow-up with any relevant Medication Changes
• Before Hospital Admissions
• After Hospital Discharge
• Any Transitions in care

66. Medication Management; Drug Optimization
• Medication Questions?
• Right Medication?
• Right Dose?
• Right Frequency?
• Adherence Questions?
• Taking as prescribed?
• Why not? Aids to improve adherence? Packaging? Medication
Synchronization?
• Patient Engagement?

67. Thank you!