The Art of Deprescribing
First do no harm: a real need to deprescribe in older patients | MJA Online Sept 22nd (1)
The benefits and harms of deprescribing | MJA Online Sept 22nd (2)
Emperor Joseph II: My dear young man, don’t take it too hard. Your work is ingenious. It’s quality work. And there are simply too many notes, that’s all. Just cut a few and it will be perfect.
Mozart: Which few did you have in mind, Majesty?
Amadeus, 1984
(Image © Depositphotos.com/phpdopus)
Adverse events from medications are a very significant cause of morbidity and cost, especially in older people.
Up to 30% of hospital admissions for patients over 75 years of age are medication related, and up to three-quarters are potentially preventable. Up to 40% of people living in either residential care or the community are prescribed potentially inappropriate medications. In both hospital and primary care settings, about one in five prescriptions issued for older adults are deemed inappropriate.
Polypharmacy in older people is associated with decreased physical and social functioning; increased risk of falls, delirium and other geriatric syndromes, hospital admissions, and death; and reduced adherence by patients to essential medicines. (1)
Is your patient receiving a medication inappropriately? According to the evidence, almost certainly, if they are on 7 or more different pills.
The solution to polypharmacy is to develop a culture of deprescibing, according to this article in the Medical Journal of Australia by Ian A Scott, Director of Internal Medicine and Clinical Epidemiology at Princess Alexandra Hospital, Brisbane et al.
The evidence suggests deprescribing will produce more benefits than harms, and can be done safely, according to another article in the MJA by Emily Reeve, Division of Health Sciences, University of South Australia.
The art of deprescribing is knowing which medications to stop, and when. As Mozart suggested to the Emperor, it’s tricky.
Both articles have suggested de-prescribing strategies.
This is my approach to deprescribing
1. What medications is this patient actually taking?
Usually, any similarity between our medication list, the pharmacist’s dispensing history and what the patient is swallowing is just a co-incidence.
(perhaps the patient would benefit from a Home Medications Review?)
2. Plan for de-prescribing at the time of prescribing.
A medication once prescribed gains an inertia that requires energy to stop, particularly in nursing home patients. It is often easier to just keep on rolling along.
When you do prescribe a new medication, also prescribe a review date to check that is doing its job.
Is it making a difference?
Is it causing a problem?
3. Which of the medications that are being taken by the patient are no longer useful?
Is the medication doing more harm than good?
Is the indication for which they were started now no longer relevant?
Have the symptoms for which they were started resolved? (has their dizziness resolved? do they still have reflux? did they ever really have angina? osteoporosis? significant hyperlipdaemia)
Will the drug only be of benefit if they live to age 120?
Is it one of the ‘usual suspects‘?
Drugs that are high risk for adverse reactions in the elderly are in the Beers and STOPP lists?
A printable card version of the Beer criteria is here.
4. Which medication would the patient like to stop first?
Start with one medication, and gradually reduce it till ‘de-prescribed’.
Then repeat
Usual Suspects
These are the ‘usual suspects’ in my patients – drugs that often continue to be prescribed beyond their usefulness or without an ongoing indication, or drugs that may be doing more harm than good.
In your experience, what should be added to this list?
- Aspirin without indication
- Benzodiazepines
- Statins for primary prevention
- Any other cholesterol-lowering drug
- Nitrates where there is no angina
- Digoxin without AF
- Sulphonylureas or other glucose lowering agents where HbA1C is below the appropriate target for their age and co-morbidity
- Biphosphantes without fractures
- Anti-depressants where depression is long gone, or in the presence of dementia
- Long term Neuroleptics for behaviour in nursing homes
- Stemetil and Maxalon
- PPIs, especially at high dose
- Prednisone when noone can remember why it was started
- Muscle relaxants and antispasmodics for gut or urine when symptoms are no longer present
- Analgesics when pain has gone
- NSAIDS when pain has gone
- Lyrica when neuralgia has gone
- Frusemide
- ACE Inhibitor plus ARB
- Laxatives
- Vitamins, Glucosamine, Fish Oil
- Ventolin and other puffers without ongoing asthma
Over treatment of Mild Hypertension – Too Much Medicine? | The BMJ
Mild hypertension in people at low risk | The BMJ
As the ‘threshold’ level of hypertension has been lowered over the years, more and more people have been diagnosed with hypertension.
A 2012 Cochrane review of people with mild hypertension ( less than 160 systolic) found that treatment with an antihypertensive drug did not reduce any outcome – including total mortality, total cardiovascular events, coronary heart disease or stroke.
Nonetheless, most people with mild hypertension are commenced on pharmacological treatment.
This article in the BMJ examines the evidence and concludes:
Read MoreOveremphasis on drug treatment risks adverse effects, such as increased risk of falls, and misses opportunities to modify individual lifestyle choices and tackle lifestyle factors at a public health level.
Lowering definitions of hypertension has led to identification and drug treatment of larger populations of patients despite lack of evidence that drugs reduce morbidity or mortality
Cholesterol Tests – non fasting is OK
Tools for Practice this week confirmed that it is unnecessary (? and cruel) to make our patient fast for a cholesterol test.
The differences between fasting and non fasting levels are not clinically significant.
Bottom-line: Minimal differences exist between fasting and non-fasting HDL, LDL, and total cholesterol (TC). Also, non-fasting HDL and non-HDL levels correlate with future CVD events. Therefore, fasting for lipid testing is not required.
The evidence is outlined here.
I wonder how long it will take this recommendation to be commonly adopted. I bet there are still lines at the path lab at 7.30 each morning for years to come.
Tools for Practice is an excellent service provided by the Alberta College of Family Physicians (ACFP). You can sign up at http://bit.ly/signupfortfp.
Read MoreSafe and effective medicines use by consumers
A recent Cochrane review looked at interventions to improve safe and effective medicines use by consumers.
Medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.
Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:·
simplified dosing regimens
interventions involving pharmacists in medicines management, such as medicines reviews and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up
Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:·
delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;·
practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives:
education delivered with self-management skills training, counselling, support, training or enhanced follow-up;
financial incentives
Immunisation Uptake
Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects.
These included
- organisational interventions;
- reminders and recall;
- financial incentives;
- home visits;
- free vaccination;
- lay health worker interventions;
- and facilitators working with physicians to promote immunisation uptake.
Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.
Summary
There are many different potential pathways through which consumers’ use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.
Read MoreShould we screen for diabetes? should we treat for diabetes intensively? The ADDITION-Europe Study
Sandbæk A1, Griffin SJ, Sharp SJ, Simmons RK, Borch-Johnsen K, Rutten GE, van den Donk M, Wareham NJ, Lauritzen T, Davies MJ, Khunti K.
It makes sense that we should screen people for diabetes and when found treat them intensively. What does the evidence show?
In this recent study, 2816 people with screening detected diabetes in 343 general practices in Denmark, the Netherlands and the UK.
Half received ‘routine care’ and half had target-driven intensive management.
It must have been disappointing for the researchers that there was no significant reduction in the frequeny of microvascular events at 5 years.
The same study has earlier reported that there was not a significant reduction in macrovascular events (cardiovascular mortality and morbidity, revascularisation, and non-traumatic amputation)
This is despite the patients having better HbA1C, Chol and BP levels.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60698-3/abstract
Read More