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Study, Jan/19: "De-prescribing Is an Essential Part of Good Prescribing"


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Abstract:

 

https://www.ncbi.nlm.nih.gov/pubmed/30600973

 

Full Study:

 

https://www.aafp.org/afp/2019/0101/p7.html

 

 

 

BARBARA FARRELL, PharmD, FCSHP, Bruyère Research Institute and University of Ottawa, Ottawa, Ontario, and University of Waterloo, Waterloo, Ontario

 

DEE MANGIN, MBChB, DPH, FRNZCGP, McMaster University, Hamilton, Ontario

 

Am Fam Physician. 2019 Jan 1;99(1):7-9.

 

Related Practice Guidelines: Deprescribing Benzodiazepine Receptor Agonists for Insomnia in Adults and Deprescribing Antipsychotics for Behavioral and Psychological Symptoms of Dementia and Insomnia.

 

See related articles from FPM: Deprescribing Unnecessary Medications: A Four-Part Process and What Needs to Change to Make Deprescribing Doable

 

Nearly one-half of older adults take five or more medications,1 and as many as one in five of these prescriptions is potentially inappropriate.2 Older adults prescribed more medications are more likely to be hospitalized for an adverse drug reaction.3 Moreover, adverse drug reactions account for more morbidity and mortality than most chronic diseases,4,5 with death rates higher than many common cancers.6,7

 

Polypharmacy is a clinical challenge because the health care system is geared toward starting medications, not reducing or stopping them, and guidelines typically include recommendations for initiating medications, but not stopping them. Although any medication may offer potential benefit, each also has potential harm. When combined, the risk of interactions with other medications or conditions or cumulative harms can outweigh the benefits. This means prioritization for ongoing treatment is an essential skill for clinicians. One component of good prescribing is deprescribing, which is defined as adjusting medications down to the minimum effective dosage or stopping them when a patient's health status changes in a way that medication burden or potential for harm outweighs the benefit of the medication.

 

Discussions about deprescribing with patients and families provide a prime opportunity for person-focused care and shared decision making. There are four important medication issues to discuss with patients as they get older: (1) the way older bodies respond to and process medication changes,8 which often results in different surrogate targets9 and lower medication dosages to avoid adverse effects while achieving the same benefit; (2) the weaker evidence regarding medication effectiveness, especially in patients who have multiple comorbidities and who are frail10,11; (3) the additive adverse effects from medication burden12; and (4) the possible evolving goals of treatment as patients near the end of life.13 These issues can introduce patients to the idea of choice regarding continuing or deprescribing medications, which facilitates a discussion of options and naturally leads to an exploration of preferences.14

 

Patients would like to take fewer medications if they could, but often rely on clinicians to take the initiative to start the conversation.15 These conversations should be focused on helping patients understand that reducing or stopping medications maintains the best quality of life possible while still maximizing the benefit of medications in the areas important to the patient, where there is good evidence for ongoing benefit in this age group.

 

The five steps to individualize deprescribing practices to each patient are (1) to identify potentially inappropriate medications; (2) to determine if the medication dosage can be reduced or the medication stopped; (3) to plan tapering; (4) to monitor (for discontinuation symptoms or the need to restart) and support the patient; and (5) to document outcomes16,17  (Table 1). This process seems fairly straightforward; however, each step requires time, careful thought, preparation, and conversation. It is not necessary, nor always possible, to take all these steps at once; leveraging the longitudinal relationship of family medicine and iterative monitoring can have a big effect. Some simple ways to start include:

 

    Assessing one particular adverse effect across all medications (e.g., additive anticholinergic effects affecting cognition).12

 

    Routinely asking if a patient's problem is caused by his or her medication (e.g., falls, cognitive impairment).

 

    Looking at “legacy prescribing,”16 which is when medications are initially prescribed for an intermediate duration, but continued indefinitely (e.g., proton pump inhibitors, selective serotonin reuptake inhibitors, benzodiazepines); for example, modifying the prescribing system to flag when the course of intended treatment is complete.

 

    Choosing specific medications on which to focus; for example, target medications known to have significant changes in metabolism or excretion or effects in older persons (e.g., beta blockers).

 

    Choosing one or two patients per day with whom to start deprescribing conversations.

 

Click "Full Study" link above to see the rest, including tables, charts, links and references.

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