Patients with depression often have a dangerous combination of drugs at home

One in seven people with dementia living outside of nursing homes were on over-the-counter prescriptions for three or more drugs that worked on the central nervous system (CNS), claims data showed Part D Medicare.

Of nearly 1.2 million Medicare beneficiaries with depression, 13.9% were prescribed CNS active polypharmacy, defined as more than 30 days of overdose for at least three antipsychotic drugs, antipsychotics, anti-epileptics, benzodiazepines, neo-benzodiazepine receptor agonist hypnotics, or opioids, reported by Donovan Maust, MD, MS, University of Michigan at Ann Arbor, and co-authors in JAMA.

Gabapentin (Neurontin) – a drug approved for seizures, zero pain, and non-stop leg syndrome commonly used for off-label symptoms – was the most common medication and was associated with 33 % of polypharmacy days.

Prescribing CNS active polypharmacy “is considered inappropriate by the American Geriatrics Association Beers Criteria because it increases the risk of falls-related injuries and affects psychiatry,” Maust said. “The specific combinations of opioids with benzodiazepine, antipsychotic, or anti-epileptic are of particular concern as they increase the risk of respiratory obstruction and death,” he said. MedPage today.

“Apart from the harms, it’s not so clear that these combinations are helpful,” Maust said. “Gabapentin is a type of poster child for limited evidence of benefit. While it is introduced and classified as an anti-epileptic medication, I suspect the majority of use off-label for chronic pain. “

This is the first review of active CNS polypharmacy in older adults living in the community with dementia, Maust noted. “In general, this type of order has been more closely studied in nursing home settings,” he said.

The study showed Medicare beneficiaries who had Part D coverage in 2018, including 1,159,968 older adults with depression with a median age of 83. About two-thirds (65.2%) were women; 39.7% had Alzheimer’s disease, and 14.6% had vascular dementia.

Of 161,412 patients who met the criteria for CNS active polypharmacy, the median number of polypharmacy days was 193. Approximately 29% were open to five or more medications, and 5.2% were open to five or more treatment classes.

The majority of dementia patients (85.6%) who received active CNS polypharmacy had non-cancerous pain, typically arthritis and back pain. Nearly half (48.1%) were depressed, 44.3% were anxious, and 15.0% had insomnia.

Almost every day (92%) polypharmacy included an antidepressant. Approximately half (47.1%) were antipsychotic, 40.7% were benzodiazepine, and 32.3% were opioid. The most common medication class combination was antidepressant, anti-epileptic, and antipsychotic, which represented 12.9% of polypharmacy days.

After gabapentin, the next most prescribed medications to polypharmacy were trazodone at 26.0% and quetiapine (Seroquel) at 24.4%. “I suspect that quetiapine, although considered an antipsychotic, is often used for sleep or for anxiety,” Maust noted.

The remaining drugs in the top 10 spots were the antidepressant drugs mirtazapine (Remeron) at 19.9%, sertraline (Zoloft) at 18.7%, escitalopram (Lexapro) at 14.7%, and duloxetine (Cymbalta) at 14.5%. , followed by three benzodiazepines: lorazepam (Ativan) at 12.9%, clonazepam (Klonopin) at 12.0%, and alprazolam (Xanax) at 12.0%. The most common opioids were hydrocodone (11.5%) and tramadol (9.2%).

Results are limited to Medicare Part D beneficiaries in 2018. In 2019, the FDA issued a warning that severe respiratory problems could occur in patients taking gabapentin or a similar drug, pregabalin (Lyrica ), with opioids or other drugs that depress the central nervous system. .

The study has other limitations, said Maust and co-authors. Applications may have given too much attention to polypharmacy if orders were filled but not taken, or if they were used just as needed. Without knowledge of symptoms or dosages, it is not possible to assess whether a prescribed drug combination was appropriate.

The researchers are now looking at which provider prescribed each drug to patients with active CNS polypharmacy to identify patterns and opportunities to modify or implement education systems after hospitalization or other events.