Deprescribing

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Deprescribing refers to the reduction in dose and/or stopping of medication that may be causing harm, may no longer be providing benefit, or may be considered inappropriate.[1][2] The process of deprescribing should be planned and supervised by health care professionals. The goal of deprescribing is to reduce medication burden and harm, while maintaining or improving quality of life. It is often applied for those with chronic conditions, for the elderly and for those who have a limited life expectancy.[3] In all of these situations, certain medications may contribute to an increased risk of adverse events, and people may benefit from a reduction in medication use.

The term inappropriate medication designates medications that, for a given patient, present a high risk of adverse events, are no longer required, or have an unfavourable risk:benefit ratio, i.e., potential harm outweighs benefits.

Reasoning

Older people are the heaviest users of medications, and frequently take five or more medications (polypharmacy). Polypharmacy is associated with increased risks of adverse events, drug interactions, falls, hospitalization, cognitive deficits [4][unreliable medical source?] and mortality.[5] Thus, optimizing medication through targeted deprescribing is a vital part of managing chronic conditions, avoiding adverse effects and improving outcomes.

Evidence base

Deprescribing is a feasible and safe intervention.[6] Deprescribing results in fewer medications with no significant changes in health outcomes.[7][unreliable medical source?] By deprescribing medications, prescribers are often able to improve patient function, generate a higher quality of life and reduce bothersome signs and symptoms. For example, targeted deprescribing can improve cognition in the elderly while also improving adherence to other drugs.[3] Deprescribing has also been linked to lower fall risk and global improvements in health.,[3][8] Deprescribing can also reduce the complexity of medication schedules, this complexity being a known barrier for patients trying to adhere to prescribed therapies.[9] A systematic review of deprescribing studies for a wide range of medications, including diuretics, blood pressure medication, sedatives, antidepressants, benzodiazepines and nitrates, concluded that adverse effects of deprescribing were rare.[10][11]

Risks

It is possible for the patient to develop adverse drug withdrawal events (ADWE).[12] These symptoms may be related to the original reason why the medication was prescribed, to withdrawal symptoms or to underlying diseases that have been masked by medications.[13] ADWEs can generally be minimized or avoided by tapering the dose slowly and carefully monitoring for symptoms. Prescribers should be aware of which medications require tapering and which can be safely stopped suddenly. People should never abruptly stop a medication without working with the prescriber.

Monitoring

Deprescribing requires detailed follow-up and monitoring, not unlike the attention required when starting a new medication. It is recommended that prescribers frequently monitor "relevant signs, symptom, laboratory or diagnostic tests that were the original indications for starting the medication" as well as for potential withdrawal effects.[11]

Helpful tools

Several tools have been published to make prescribers aware of inappropriate medications for patient groups. For example, the Beers Criteria and the STOPP/START criteria present medications that may be inappropriate for use in the elderly.[14] RxFiles, an academic detailing group based in Saskatchewan, Canada, has developed a tool to help long-term care providers identify potentially inappropriate medications in their residents.[15] Tasmanian Medicare Local have created resources to help clinicians deprescribe.[16]

Barriers

Although many trials have successfully resulted in a reduction in medication use, there are some known barriers to deprescribing. A systematic review identified four prescriber factors that both enable and are barriers to deprescribing. These were identified as the prescriber (e.g., beliefs, attitudes, knowledge, skills, behaviour) and their work environment (e.g., patient, work setting, health system and cultural factors).[17] A similar systematic review on patient barriers [18] identified four consumer factors. These were the consumer agreement with ‘appropriateness’ of deprescribing, if there was a ‘process’ for cessation, and ‘influences’ to cease medication, as well as a ‘fear’ of cessation and ‘dislike’ of medications.

Summary

"Simply because a patient has tolerated a therapy for a long duration does not mean that it remains an appropriate treatment. Thoughtful review of a patient’s medication regimen in the context of any changes in medical status and potential future benefits should occur regularly, and those agents that may no longer be necessary should be considered for a trial of medication discontinuation."[19][unreliable medical source?] In the future, more research of high methodological quality examining the effects of deprescribing would help with developing guidelines for tapering and monitoring medications.

See also

  1. Beers Criteria
  2. Overmedication
  3. Polypharmacy
  4. Prescription cascade
  5. Drug interaction

References

  1. ^ Reeve, E; Gnjidic, D; Long, J; Hilmer, S (2015). "A systematic review of the emerging definition of "deprescribing" with network analysis: implications for future research and clinical practice". Br J Clin Pharmacol. 80: 1254–1268. doi:10.1111/bcp.12732.
  2. ^ Thompson, W; Farrell, B (May 2013). "Deprescribing: what is it and what does the evidence tell us?". Can J Hosp Pharm. 66 (3): 201–202. doi:10.4212/cjhp.v66i3.1261.
  3. ^ a b c Gnjidic, D; Le Couteur, DG; Kouladjian, L; Hilmer, SN (2012). "Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes". Clin Geriatr Med. 28: 237–253. doi:10.1016/j.cger.2012.01.006.
  4. ^ Cao, YJ; Mager, DE; Simonsick, EM; et al. (March 2008). "Physical and cognitive performance and burden of anticholinergics, sedatives, and ACE inhibitors in older women". Clin Pharmacol Ther. 83: 422–429. doi:10.1038/sj.clpt.6100303. PMID 17713474.
  5. ^ Hajjar, ER; Cafiero, AC; Hanlon, JT (December 2007). "Polypharmacy in elderly patients". Am J Geriatr Pharmacother. 5 (4): 345–351. doi:10.1016/j.amjopharm.2007.12.002. PMID 18179993.
  6. ^ Page, A.T.; Clifford, R.M.; Potter, K.; Schwartz, D.; Etherton-Beer, C.D. (2016). "The feasibility and the effect of deprescribing in older adults on mortality and health: A systematic review". British Journal of Clinical Pharmacology. doi:10.1111/bcp.12975.
  7. ^ Potter, K.; Flicker, L.; Page, A.; Etherton-Beer, C. (2016). "Deprescribing in frail older people: a randomised controlled trial". PLOS ONE. 11 (3): e0149984. doi:10.1371/journal.pone.0149984.
  8. ^ Garfinkel, D; Zur-Gil, S; Ben-Israel, J (2007). "The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people". IMAJ. 9: 430–34.
  9. ^ Hilmer, SN; McLachlan, AJ; Le Couteur, DG (Jun 2007). "Clinical Pharmacology in the Geriatric Patient". Fundam Clin Pharmacol. 21 (3): 217–30. doi:10.1111/j.1472-8206.2007.00473.x.
  10. ^ Iyer, S; Naganathan, V; McLachlan, AJ; Le Couteur, DG (2008). "Medication withdrawal trials in people aged 65 years and older: a systematic review". Drugs Aging. 25 (12): 1021–31. doi:10.2165/0002512-200825120-00004.
  11. ^ a b Garfinkel, D; Mangin, D (2010). "Feasibility study of a systematic approach for discontinuation of multiple medications in older adults". Arch Intern Med. 170 (18): 1648–54. doi:10.1001/archinternmed.2010.355.
  12. ^ Graves T, Hanlon JT, Schmader KE, Landsman PB, Samsa GP, Pieper CF, Weinberger M. Adverse events after discontinuing medications in elderly outpatients. Arch Intern Med. 1997 Oct 27;157(19):2205-10.
  13. ^ Woodward, Michael C. (December 2003). "Deprescribing: Achieving better health outcomes for older people through reducing medications" (PDF). J Pharm Pract Res. 33: 323–328. doi:10.1002/jppr2003334323.
  14. ^ Gallagher, P; Ryan, C; Byrne, S; Kennedy, J; O'Mahony, D (2008). "STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation". Int J Clin Pharmacol Ther. 46: 72–83. doi:10.5414/cpp46072. PMID 18218287.
  15. ^ "Long-Term Care & Residential Care: Evidence-Based Resources". RxFiles. January 2016.
  16. ^ "Deprescribing Documents now Available for Download". Consultant Pharmacy Services.
  17. ^ Anderson, K; Stowasser, D; Freeman, C; Scott, I (8 December 2014). "Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis". BMJ Open. 4 (12): e006544. doi:10.1136/bmjopen-2014-006544. PMC 4265124. PMID 25488097. open access
  18. ^ Reeve, Emily; To, Josephine; Hendrix, Ivanka; Shakib, Sepehr; Roberts, Michael S.; Wiese, Michael D. "Patient Barriers to and Enablers of Deprescribing: a Systematic Review". Drugs & Aging. 30: 793–807. doi:10.1007/s40266-013-0106-8.
  19. ^ Linsky, Amy; Simon, Steven R. (8 April 2013). "Reversing Gears: Discontinuing Medication Therapy to Prevent Adverse Events: Comment on "Proton Pump Inhibitors and Risk of 1-Year Mortality and Rehospitalization in Older Patients Discharged From Acute Care Hospitals". JAMA Intern Med. 173 (7): 524–525. doi:10.1001/jamainternmed.2013.4068.

Further reading