Deprescribing: When is it appropriate and what are the benefits?

What is Polypharmacy?1-5

Polypharmacy is defined as the concurrent use of multiple medications where risk of concomitant use of the medications outweighs potential benefits. Polypharmacy is currently is a large concern in the elderly population because they are most at risk for fractures, confusion, hospital visits, and often have poor elimination of medications as they age. 4 Many patients are prescribed new medications without discontinuation of currently prescribed medications potentially leading to harmful drug interaction or duplications of therapy. This would eventually lead to additional medications being added to treat a side effect from an already unnecessary drug. Ultimately, outcomes from polypharmacy may lead to negative consequences such as:

  • Lower medication adherence due to increased pill burden
    • Nonadherence plays a role in about 50% of treatment failure, 25% of patient hospitalization, and about 125,000 patient deaths yearly in the US
    • The rate of nonadherence for patients taking 4 or more medications is about 35%5
  • Increased unnecessary drug and treatment costs (up to 30%)5
  • Increased adverse drug events from drug interactions or duplications.
    • Approximately 88% of patients in an ambulatory setting are at an increased risk of experiencing an adverse drug event if they are taking 5 or more medications vs. patients taking fewer medications5
  • Medications being added solely to treat a side effect from an already unnecessary drug
  • Preventable hospital visits
  • Patient dissatisfaction and lower quality of life
  • Lower reimbursement for providers using value-based performance models

What is Deprescribing?1

Deprescribing is the discontinuation or tapering of a medication that has no active indication, is not beneficial as long term therapy, or has potential risks that now outweigh the benefits. Deprescribing aims to remove a medication without negatively impacting the patient’s quality of life and maintaining quality of care. The overall goals of deprescribing are:

  • Optimization of patient therapy and health outcomes
  • Reduction in the amount of hospital visits and costs
  • Improved medication adherence
  • Improved patient satisfaction and quality of life
  • Increased reimbursement for providers under value-based performance models
  • Reduction in incidence of side effects
  • Fall and fracture risk reduction

What are some common types of medications that may be deprescribed safely in specific clinical situations?1,2

PPIs – Proton pump inhibitors reduce the production of acid by irreversibly blocking the acid producing enzymes on the stomach wall. Unfortunately, the long term consequence of this leads to an increased risk of a C. diff infection, hypomagnesemia, and bone loss/fractures for the elderly. PPIs are generally recommended for no more than 8 weeks for most indications. Some exceptions where PPIs are taken long-term include Barrett’s esophagus, chronic NSAID users with high bleed risk, severe esophagitis, or documented history of bleeding GI ulcers.

For more information on deprescribing PPIs:

Antihyperglycemics – Geriatric patients tend to run a higher risk of experiencing symptoms related to hypoglycemia and poor renal function. Careful monitoring of blood glucose levels, renal function, and patient reported symptoms must be taken into account to decide whether to switch from an antihyperglycemic agent with a higher risk of hypoglycemia to one with a lower risk, dose adjust, or discontinue.

For more information on deprescribing antihyperglycemic medications:

Antipsychotics – Many antipsychotics have adverse effects of sedation, confusion, and loss of balance. This is a serious health risk for geriatric patients or any patients with a high risk of falls or fractures. With deprescribing, it is important to assess the indication for the antipsychotic in order to appropriately continue, taper, or discontinue the medication. If the patient is tapering or discontinuing but experiences problems with insomnia, a safer alternative medication or patient education on good sleep hygiene could be recommended.

For more information on deprescribing antipsychotics:

Benzodiazepines – Like antipsychotics, many benzodiazepines have adverse effects of sedation, confusion, and loss of balance. Many of these patients have been on benzodiazepine therapy for extended intervals and special caution must be taken for deprescribing these medications as withdrawal can lead to life threatening symptoms. Deprescribing using a slow taper is recommended for all patients over 65, regardless of duration of therapy. The length of the taper depends on the length of time on benzodiazepine therapy.

For more information on deprescribing benzodiazepines:

Opioids – patients managing chronic pain often build tolerance to their opioid pain medication. This often requires escalating doses in order to receive the same level of pain control. However, this dose escalation could expose the patient to fatal risks, such as respiratory depression. Providers should consider gradually tapering down of doses and consider non-opioid or non-pharmacologic options when managing pain.

For more information on deprescribing opioids:

Other medications where deprescribing may be beneficial2,3,5

Canadian Deprescribing Network: contains various algorithms and clinical data that supports deprescribing various classes of medications. For more information, visit https://www.deprescribingnetwork.ca/deprescribing

  • NSAIDs – Geriatric patients run the highest risk for renal damage and gastrointestinal bleeding.
  • Bisphosphonates – there is little evidence of improved risk of fractures after 5 years of therapy in elderly patients. Consider discontinuation or a drug holiday.
  • Beta blockers – Geriatric patients generally have a poorer response compared to younger populations which could cause bradycardia. Studies have shown that in elderly populations, there isn’t a mortality benefit in continuing beta blockers.
  • Stool softeners – Patients that are hospitalized often are put on stool softeners to reduce constipation from non-mobility or with their treatment regimen. However these are sometimes continued upon discharge, which could contribute to polypharmacy especially if the patient does not frequently experience constipation.
  • Anticoagulants – if there is a low chance of reoccurrence of a VTE, anticoagulants shouldn’t be taken indefinitely. Anticoagulants are typically prescribed from 3 months to an upwards of 1 year.
  • Inhalers – if symptoms of asthma are well controlled for at least 3 months, consider using a step down approach for lowering the amount of inhalers needed.

Solutions to improve medication adherence and identify opportunities for deprescribing3

  • MTM services – Providers and pharmacy will make a concerted effort for the patient in order to discontinue medications where there are no indications, if a medication does not help to improve health outcomes, or if side effects are intolerable.
  • Engaging with patients or caretakers – Patients or caretakers will have a better understanding the rationale of deprescribing if they are informed of the potential risks of therapy continuation or lack of benefit to the patient. The caregiver can often provide education that may improve the patient/provider relationship.
  • Provider education – Some providers are hesitant in changing their prescribing habits. Helpful tools such as the BEERs criteria and other deprescribing guidelines can help aid providers in making the decision to deprescribe. The BEERs list is written by the American Geriatrics Society (AGS) in order to help providers deprescribe medications that are unnecessary or risks outweighing the benefits. It contains types of medications that increase the risk of falls for geriatric patients or have increased sedation/confusion such as benzodiazepines. Pharmacist involvement with deprescribing can help reduce medication errors, lower unnecessary drug costs, improve patient health outcomes, and strengthen the prescriber/pharmacist relationship.
  • Routine follow-up with patients – Providers and pharmacists may evaluate the appropriateness of continuation of therapy. This will determine if a prescription renewal is authorized.
  • Pill burden – Use longer acting formulations or combination pills to reduce the total number of pills taken daily.
  • Reduce preventable errors – Recommend patients to limit their general providers and pharmacies to only one if possible.

What other useful deprescribing tools are available?1

  • www.deprescribing.org
  • A mobile app is available for mobile iOS and Android devices called “IAM Medical Guidelines”

References

  1. Farrell B, Pottie K, Rojas-fernandez CH, Bjerre LM, Thompson W, Welch V. Methodology for Developing Deprescribing Guidelines: Using Evidence and GRADE to Guide Recommendations for Deprescribing. PLoS ONE. 2016;11(8):e0161248.
  2. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019.
  3. DiMatteo MR, Giordani PJ, Lepper HS, et al. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care. 2002;40(9):794-811.
  4. Sirois C, Ouellet N, Reeve E. Community-dwelling older people’s attitudes towards deprescribing in Canada. Res Social Adm Pharm. 2017;13(4):864-870.
  5. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57-65.

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