Deprescribing

Deprescribing is the process of intentionally stopping a medication or reducing its dose to improve the person's health or reduce the risk of adverse side effects. Deprescribing is usually done because the drug may be causing harm, may no longer be helping the patient, or may be inappropriate for the individual patient's current situation.[1][2] Deprescribing is the opposite of prescribing a drug. It can help correct polypharmacy and prescription cascade.

Deprescribing is often done with people who have multiple chronic conditions, for elderly people, and for people 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 the amount of medication taken. The goal of deprescribing is to reduce medication burden and harm, while maintaining or improving quality of life. "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."[4]

The process of deprescribing can be planned and supervised by health care professionals. The definition and concept of deprescribing remain contentious with people using the term deprescribing to mean different things.[5]

Demographics

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, and mortality. 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] 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.[8][9]

By deprescribing medications, prescribers are often able to improve patient function, generate a higher quality of life, and reduce bothersome signs and symptoms. Deprescribing has been shown to reduce the number of falls that people experience, but not to change the risk of having the first fall.[6] A large systematic review of deprescribing studies found that most health outcomes remained unchanged as an effect of deprescribing.[6] The absence in a change has been viewed as a positive outcome as the medications can often be safely withdrawn without altering health outcomes. This absence of an effect means that older people may not miss out on potentially beneficial effects of using medications as a result of deprescribing.

Targeted deprescribing can improve adherence to other drugs.[3] Deprescribing can reduce the complexity of medication schedules. Complicated schedules are difficult for people to follow correctly.

The European Journal of Hospital Pharmacy carried a special issue in 2017 dedicated to deprescribing and associated issues, with editorials and research articles[10]. An article in 2018 highlighted developments in this topic, with recommnedations for education and awareness in staff and the public.[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] For some medications, ADWEs can generally be minimized or avoided by tapering the dose slowly and carefully monitoring for symptoms. Prescribers should be aware of which medications usually require tapering (such as corticosteroids and benzodiazepines), and which can be safely stopped suddenly (such as antibiotics and nonsteroidal anti-inflammatory drugs).

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.[9]

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 barriers to deprescribing:

  • the prescriber's beliefs, attitudes, knowledge, skills, and behaviour[17]
  • the prescriber's work environment, including work setting, health system and cultural factors[17]
  • the patient's agreement that deprescribing was appropriate,[18]
  • the patient's need for a structured process for cessation,[18]
  • the patients' need for influences or reasons to cease medication,[18] and
  • patients' fears about cessation or dislike of medications.[18]

See also

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. PMC 4693477.
  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. PMC 3694945.
  3. 1 2 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. ↑ 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.
  5. ↑ Page, Amy; Clifford, Rhonda; Potter, Kathleen; Etherton-Beer, Christopher. "A concept analysis of deprescribing medications in older people". Journal of Pharmacy Practice and Research: n/a–n/a. doi:10.1002/jppr.1361. ISSN 2055-2335.
  6. 1 2 3 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. 82: 583–623. doi:10.1111/bcp.12975. PMID 27077231.
  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. PMC 4778763. PMID 26942907.
  8. ↑ 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.
  9. 1 2 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.
  10. ↑ "European Journal of Hospital Pharmacy: 24 (1)". Eur J Hosp Pharm. 24 (1). 1 January 2017. ISSN 2047-9956.
  11. ↑ Barnett, Nina; Garfinkel, Doron (27 January 2018). "Deprescribing one year on: challenging the first iatrogenic epidemic". Eur J Hosp Pharm: ejhpharm–2017–001482. doi:10.1136/ejhpharm-2017-001482. ISSN 2047-9956.
  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. 1 2 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.
  18. 1 2 3 4 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.

Further reading

  • "European Journal of Hospital Pharmacology TOC". Eur J Hosp Pharm. 24 (1). Jan 2017. A special issue on deprescribing
  • Rochon, Paula A.; Gurwitz, Jerry H. (25 October 1997). "Optimizing drug treatment for elderly people: the prescribing cascade". BMJ. 315: 1096–1099. doi:10.1136/bmj.315.7115.1096.
  • Hilmer, Sarah N.; Gnjidic, Danijela; Le Couteur, David G. (December 2012). "Thinking through the medication list – Appropriate prescribing and deprescribing in robust and frail older patients". Australian Family Physician. 41 (12): 924–928.
  • "A practical guide to stopping medicines in older people". Best Practice Journal. Best Practice Advocacy Centre New Zealand (27): 10–23. April 2010.
  • Alexander, G. Caleb; Sayla, Maliha A.; Holmes, Holly M.; Sachs, Greg A. (11 April 2006). "Prioritizing and stopping medicines". CMAJ. 174 (8): 1083–1084. doi:10.1503/cmaj.050837. PMC 1421477. PMID 16606954.
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