rxPassport Pharmacy Newsletter
 
March 2015
 
 
Deprescribing: Less is More
 
Meet Your Patient
 
Donna (87) presents in the pharmacy with her daughter and a very large plastic bag with at least 14 different medications. Her daughter states her mother recently fell and seems very confused. Donna mentions that she just does not know what to do anymore.
 
Her daughter thinks that her mother is taking too many medications and wants to pull her off everything.
 
What can you do for this patient?
 
Creating a Culture of Deprescribing
 
Almost every pharmacist in primary care has seen a patient like Donna. She is taking a large number of medications that seem to be causing issues. For many patients, a decrease in the number of medications can actually improve outcomes and quality of life.
 
Appropriate medication management in the elderly not only involves prescribing indicated medications but recognizing and stopping ones that are no longer appropriate. Polypharmacy is an often necessary evil in the elderly 1. The problem is not just the number of medications but also the types of medications used in this population. Initially medications are often prescribed appropriately but often become unsuitable in old age. Inappropriate prescribing and potentially inappropriate medications (PIMs) are medications where the benefits no longer outweigh the risks when used in older people 1, 6.
 
What can pharmacists do?
Deprescribing is the trial withdrawal or dose reduction of inappropriate, unnecessary and potentially harmful medications 5. The #1 predictor of inappropriate prescribing and adverse drug events in older patients are those with the highest number of medications 8. Pharmacists can:
 
Target candidates for deprescribing
 
Use a deprescribing lens during regular medication reviews
 
Educate patients about the role and benefits of deprescribing
 
Connect with patients’ primary prescriber to make deprescribing recommendations
Work closely with the patient and frequently monitor symptoms
 
What are the benefits of deprescribing 1,3,8,9
 
Fewer falls and hospital admissions
 
Improved cognition
 
Decreased risk of adverse drug events and drug interactions
 
Improved adherence
Reduced costs
 
 
Deprescribing is a process
 
5 Key Steps for Deprescribing 3:
 

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Obtain a complete and comprehensive medication list and history. Ensure you target high risk elderly who would benefit most from deprescribing.
 
Key patient factors to target 8:
 
I. Advancing age (>75 years)
 
II. Frail patients, limited life expectancy
 
III. 7+ medications
 
IV. Multiple prescribers
 
V. Using high risk medications (Beers and STOPP criteria)
 
Clinical Practice Tip!
 
Staff can screen patients for these risk factors at order entry to target deprescribing candidates and suggest medication reviews.
 
Deciding what to stop
 
Deprescribing is as complex as initiating a new medication; all patient and disease factors needs to be accounted for. There are tools available to aid in this decision making but should not override clinical judgement.
 

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The best way to stop inappropriate medications is to not start them in the first place. Refer to the START tool which helps to ensure appropriate pharmacotherapy in the elderly.
 
Use Beers criteria, STOPP/START tools and IPET (improving prescribing in the elderly tool) to help define and screen for high risk medications9. Also consider the appropriateness of recommended treatment targets in the elderly population. Older people are poorly represented in clinical trials that back up guideline recommendations, thus treat to target is often not suitable in these patients. CDA and CHEP guidelines have specific recommendations for treating elderly, often with changes to conventional treatment targets.
 
Top 5 drug candidates for deprescribing:
 
1. Chronic use of sleeping pills (namely, benzodiazepines and Z-drugs)
 
2. Anticoagulation
 
3. Insulin and sulfonylureas used in combination
 
4. Multiple antihypertensives
 
5. Drugs with a propensity for prescribing inertia (e.g. PPIs, docusate, statins)
 
a. “Prescribing inertia” = tendency for medications to be continued indefinitely without continued reassessment
 
How to stop medications
 
It is important to withdraw only one medication at a time, thus prioritizing which medications to stop first is needed.
 
Prioritize medications by those 3:
 
Causing adverse effects
 
Medications not being used
 
Have no indication
 
Being used irregularly for non-life threatening conditions
 
Used to combat side effects of other drug
 
General tapering recommendations 2:
 
- Individualize and monitor
  • Considerations: age, comorbidities, other medications, half-life, reason for taper, consequences of withdrawal
- Possible strategies include:
  • Halve the dose and monitor
  • Reduce dose by 25% at weekly or longer intervals and monitor
 
- Tapering can take days, weeks or months
 
- Benzodiazepines, antidepressants and opioids often require slower tapering schedules
  • You can use this resource for tapering recommendations of specific drugs, or see table 1 for common drugs causing withdrawal syndromes
- When in doubt, TAPER!
 
Always simplify the regimen when possible! Suggest combination pills, once daily or twice daily dosing and offer blister packing
Collaborate with the patient
 
Gaining patient buy-in is critical for deprescribing to be successful. Deprescribing concepts are not intuitive to patients.
 
Communication strategies for securing patient buy-in 7
Help them understand why you’re deprescribing
 
Explain the risks of ongoing treatment
 
It is not an act of abandonment or giving up, but part of high quality care
 
Emphasize the reductions in cost and pill burden
Most importantly, address all fears the patient has as fear and misunderstanding are major barriers to deprescribing.
Monitoring and follow-up
 
Close and frequent monitoring of patients undergoing a deprescribing regimen is critical to ensure success and prevent potential adverse effects. At each visit, monitor for:
 
Withdrawal syndromes, including rebound symptoms
  • E.g. benzodiazepine withdrawal or rebound hyperacidity after stopping PPIs
 
Signs of disease recurrence
 
 
Clinical Practice Tip!
 
Create an individualized follow-up program for each patient. Frequency of monitoring depends on the type of discontinued drug and health of the patient. In general, follow-up should occur 24 hours to 7 days after altering a medication. More frequent follow-up is required if the drug is more likely to cause withdrawal syndromes or other issues (table 1).
Table 1: Drugs most commonly associated with discontinuation syndromes
 

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Claudia
 
By Claudia Janiszewski, PharmD Student
 
With appreciation to Mike Boivin
 
In this issue
 
Creating a Culture of Deprescribing
 
Deprescribing is a process
 
Deciding what to stop
 
How to stop medications
 
Collaborate with the patient
 
Monitoring and follow-up
 
Interactive Poll
 
Resources
 
References
 
Pharmacy Student Blog
 
Interactive Poll
 
Q: How comfortable are you with creating a deprescribing plan for your elderly patients using long-term benzodiazepines?
 
Very comfortable
 
Somewhat comfortable
 
Not comfortable
 
I do not have many elderly patients on long-term benzodiazepines
 
 
DID YOU KNOW?
 
In a study done in Australia it was found that only 20% of the time was the use of benzodiazepines appropriate3.
 
Resources
 
BEERs criteria
 
STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions):
 
Choosing Wisely
 
BC Falls Prevention eNewsletter
 
References
 
1. Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews 2014;10:1-117.
 
2. A practical guide to stopping medicines in older people. Best Pract J 2010;27:10-23. View Source
 
3. Woodward MC. Deprescribing: achieving better health outcomes for older people through reducing medications. J Pharm Pract Res 2003;33:323-8.
 
4. Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age and Ageing 2008;37:673-679.
 
5. Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. The benefits and harms of deprescribing. MJA 2014;201(7):1-4.
 
6. American Geriatrics Society 2012. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society 2012;60(4):616–31.
 
7. Reeve E, To J, Hendrix I, Shakib S, Roberts MD, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2013;30:793-807.
 
8. Scott IA, Gray LC, Martin JH, Pillans PI, Mitchell CA. Deciding when to stop: towards evidence-based deprescribing of drugs in older populations. Evid Based Med 2013;18(4):121-124.
 
9. Frank C, Weir E. Deprescribing for older patients. CMAJ 2014. [Accessed March 16, 2015] View Source
 
 
 
 
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