Deprescribing: finding the best fit for individual patients

You have probably encountered an older person taking 12 or even 20 medications. When medication numbers add up, the risk of falls, hospitalizations and adverse drug reactions increases too.1 It can also be a lot of work for people to manage so many medications, and this may lower their quality of life.2 Some medications an older person is taking may have been started many years ago. But people change over time. As people age, their health and function may decline, shifting the balance of benefits and harms of medications.3 Peoples’ healthcare goals may also evolve. Deprescribing? I have heard of that somewhere… Deprescribing is the planned and supervised process of stopping a medication or reducing the dose when the medication is unnecessary, the harms outweigh the benefits, or it does not align with healthcare goals and treatment preferences.4 It is not about denying safe, effective medication use, but about safely backing off, when appropriate, to maximize a person’s health and well-being. Most patients are open to talking about deprescribing together with a trusted healthcare provider.5 An approach to deprescribing A medication review is an opportunity to start a deprescribing conversation. Other triggers might include care transitions and changes in health status. These conversations can be framed as a chance to review the option to continue or try stopping/reducing one or more medications.6 A general approach to deprescribing for an individual patient includes the following:6,7 1. Identifying all medications the person is taking (including OTC, complementary and alternative medications). If possible, identify each medication’s indication, and the person’s medication experience (e.g., when started, response) 2. Patient assessment (e.g., concerns or problems important to the patient, age, comorbidities, function, frailty, relevant laboratory or diagnostic data if available, patient’s healthcare goals, input from healthcare team members) 3. Based on steps 2 and 3, assess whether one or more medications may be candidates for deprescribing for the patient. Some things to think about: Consider the risk of actual or potential medication harms (could any of the patient’s present problems or conditions be caused by a drug they are taking?) Are any medications being used to treat the side effects of another medication? (i.e., a prescribing cascade, such as furosemide used to treat ankle edema caused by gabapentin) Is the medication providing ongoing benefit? (e.g., intensive diabetes management to an A1C 8 weeks in a person treated for gastroesophageal reflux disease, with no ongoing symptoms and no indication for continuing) Does the medication align with the person’s healthcare goals and preferences? (e.g., aggressive preventive medication use in a person living in long-term care) 4. Together with the patient, prioritize medications for discontinuation, thinking about: Which concerns are most important to the patient? Which medication has the greatest risk of harm? Which medication has the least benefit? Which medication is the most burdensome for the patient? 5. Develop and implement a deprescribing plan: Together with the patient: discuss and agree on which medication(s) to stop or reduce and on the method (e.g., tapering or stopping abruptly) Some medications may need to be tapered to avoid withdrawal symptoms (e.g., benzodiazepines, beta-blockers); discuss and agree on the tapering rate together with the patient Depending on the medication(s), consider deprescribing one at a time so any effects of stopping can be assessed Develop a plan for monitoring and follow-up: advise the patient on what to watch for after stopping, decide on the method and frequency of follow-up, and decide what to do if withdrawal symptoms occur (e.g., criteria for restarting the medication) Communicate the plan with other relevant healthcare providers Document your plan and the outcomes. The resources in Box 1 can provide help with these steps. How can I get started? You may not have time to take on the whole process in one visit. It might take several discussions or visits to work through the process. You may also want to focus on deprescribing for one particular medication/medication class (e.g., high-risk medications for seniors) or one problem at a time (e.g., falls).6 Whatever the approach, pharmacists need to effectively communicate and collaborate with other members of the healthcare team to make deprescribing happen in practice.8 This may include communicating about patient assessment, recommendations, planning, and responsibilities for monitoring and follow-up. Summary Deprescribing is about finding the best drug treatment for each patient. It is important to work together with patients and have open communication at all stages of the process.9 People need to understand why deprescribing is being considered, what their options are, and be involved in planning.9 Different people have different healthcare goals and different health contexts. For some people, deprescribing may make sense, and for others it might not. Wade Thompson is a pharmacist and researcher working to ensure older persons are taking medications that are necessary, effective, safe, and consistent with their healthcare goals and treatment preferences. He is an assistant professor in the Department of Anesthesiology, Pharmacology and Therapeutics in the Faculty of Medicine at University of British Columbia. He is an investigator with deprescribing.org and a member of the Therapeutics Initiative, and works clinically as a pharmacist in long-term care. References Wastesson JW, Morin L, Tan ECK, et al. An update on the clinical consequences of polypharmacy in older adults: a narrative review. Expert Opin Drug Saf 2018;17(12):1185-96. doi:10.1080/14740338.2018.1546841. Aljeaidi MS, Haaksma ML, Tan ECK. Polypharmacy and trajectories of health-related quality of life in older adults: an Australian cohort study. Qual Life Res 2022;31(9):2663-71. doi:10.1007/s11136-022-03136-9. Holmes HM, Hayley DC, Alexander GC, et al. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166(6):605-9. doi:10.1001/archinte.166.6.605. Reeve E, Gnjidic D, Long J, et al. A systematic review of the emerging definition of “deprescribing” with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol 2015;80(6):1254-8. DOI: 10.1111/bcp.12732. Weir KR, Ailabouni NJ, Schneider CR, et al. Consumer attitudes towards deprescribing: a systematic review and meta-analysis. J Gerontol A Biol Sci Med Sci 2022;77(5):1020-34. doi:10.1093/gerona/glab222. Farrell B, Mangin D. Deprescribing is an essential part of good prescribing. Am Fam Physician 2019;99(1):7-9. http://www.ncbi.nlm.nih.gov/pubmed/30600973 (accessed February 6, 2023). Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015;175(5):827-34. doi:10.1001/jamainternmed.2015.0324. Doherty AJ, Boland P, Reed J, et al. Barriers and facilitators to deprescribing in primary care: a systematic review. BJGP Open 2020;4(3):bjgpopen20X101096. doi:10.3399/bjgpopen20X101096. Jansen J, Naganathan V, Carter SM, et al. Too much medicine in older people? Deprescribing through shared decision making. BMJ 2016;2893:i2893. doi:10.1136/bmj.i2893.

Deprescribing

Deprescribing: finding the best fit for individual patients

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WADE THOMPSON

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