Potter 2016 Deprescribing a guide for medication reviews.pdf

Potter 2016 Deprescribing a guide for medication reviews.pdf
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  P R I M A R Y C A R E F O C U S Deprescribing: a guide for medication reviews Kathleen Potter, MBChB, PhD, FRACGP, Amy Page, BHsc, BPharm, MClinPharm, Rhonda Clifford, PhDFPS, Christopher Etherton-Beer, MBBS GradCertHPEd, PhD, FRACP School of Medicine and Pharmacology, University of Western Australia, Crawley, Australia INTRODUCTION Deprescribing is a new word for an old activity: theplanned cessation of non-bene 󿬁 cial medicines. Risk-modifying medicines that extend life and reduce disabil-ity  –  antihypertensives, anticoagulants, cholesterol-low-ering agents, hypoglycaemics, bisphosphonates, calciumsupplements  –  do not bene 󿬁 t someone with a life expec-tancy measured in days or weeks. Stopping such treat-ments is considered good care in people who are closeto death. Weighing the risks and bene 󿬁 ts of these typesof medicines in an older person without a life-limitingillness is more dif  󿬁 cult.Many of us will reach a very old age before we die. 1 As we age, most of us will accumulate a variety of chronic progressive symptomatic medical conditions.Consequently, as we get older, many of us will consumean increasing number of medicines intended to reducedisability and delay death. 2 Not all these medicines willcontinue to bene 󿬁 t us as we age, but deciding whichtreatments are helpful rather than harmful becomesmore challenging as the number of co-morbidities andmedicines increase.As people age, their physiology, renal and liver func-tion, body composition and cellular metabolism change,affecting the way that medicines are distributed andmetabolised within the body. 3 Consequently, medicinesthat are therapeutic in a younger adult may become lessef  󿬁 cacious and/or toxic in older adults. The risks of adverse drug interactions, adverse drug effects, drug — disease interactions and drug errors increase as the num- ber of medicines consumed increases. 4 Adverse medicineeffects are sometimes misidenti 󿬁 ed as new symptoms inolder people, causing cascade-prescribing  –  the prescrip-tion of new medicines to treat the adverse effects of exist-ing medicines. Polypharmacy and inappropriatemedicine use are increasingly recognised as a signi 󿬁 cantcause of morbidity and mortality in older people. 5 The term  ‘ deprescribing ’  was  󿬁 rst used to describe aprocess of planned medicine cessation by MichaelWoodward in 2003. 6 Interest in deprescribing as a wayto reduce inappropriate polypharmacy in older peoplehas grown signi 󿬁 cantly in the past decade. However,most deprescribing interventions reduce the consump-tion of regular medicines by less than one drug per per-son. 7,8 We recently reported a randomised deprescribingtrial in 95 frail older people living in residential care.We stopped more than four medicines per person with-out adversely affecting quality of life or survival at12 months. 9 This paper presents a brief practical  ‘ howto ’  guide for deprescribing based on our intervention.The process described below can be used whetherdeprescribing is led by a pharmacist, a geriatrician, ageneral practitioner or another health professional. DEPRESCRIBING IS AN INDIVIDUALISED,MULTI-STEP, COOPERATIVE PROCESS Step One: Identify People Suitable forDeprescribing People likely to bene 󿬁 t most from deprescribing arecommunity-dwelling older adults who take a largenumber of medicines and frail older people living in res-idential care. It is important to ensure that the personwants to reduce their medicine use as it is dif  󿬁 cult todeprescribe in someone who is not actively engagedwith the process.Deprescribing is especially challenging in people withdementia even though they may have much to gain fromthe process. People with dementia living in residentialcare take 10 long-term regular medicines on average and, because they are often physically frail with multiple co-morbidities, are at high risk of adverse drug effects anddrug — disease interactions. 10 Many commonly prescribedmedicines, such as anticholinergics, antipsychotics andsedatives, reduce cognitive performance and exacerbateconfusion in this population. 11 Consent to deprescribe isdif  󿬁 cult to establish in people with cognitive impairmentso their closest kin and primary caregivers must beengaged with and agree to the process. Address for Correspondence:  Kathleen Potter, University of Wes-tern Australia, School of Medicine and Pharmacology, 35 StirlingHwy, Crawley WA 6009, AustraliaE-mail: ©  2016 The Society of Hospital Pharmacists of Australia  Journal of Pharmacy Practice and Research  (2016)  46,  358 – 367doi: 10.1002/jppr.1298 Official Journal of    the Society of Hospital Pharmacists of Australia  Step Two: Take a Medicine-Focused History Start by making an accurate list of the medicines theperson is actually taking. In Australia, the HomeMedicines Review (HMR) is a useful service that allowsa consultant pharmacist to assemble this information inthe home and to collect additional information of whichthe general practitioner may not be aware. Ask the per-son to present all their regular and as required medici-nes, all alternative and complementary medicines, andall over-the-counter remedies at the HMR home inter-view. Record the name, dose and frequency of use of each medicine. Where possible, record when, why and by whom each medicine was started. Many people areunable to recall this information, so you may also needto inspect the dispensing records of their usual phar-macy or request more information from the referringgeneral practitioner. Ask if they have stopped takingany of their medicines. If they have stopped taking anyprescribed medicines,  󿬁 nd out the reasons why theyhave stopped. Ask speci 󿬁 c questions about commonadverse medicine effects, such as cough in people tak-ing angiotensin-converting enzyme (ACE) inhibitors,dry mouth, dry eyes and constipation in people takinganticholinergic medicines and ankle swelling in peopletaking calcium channel blockers. If adverse effects arereported,  󿬁 nd out whether the adverse effects from themedicine are tolerable or are worse than the symptomsof the condition being treated. Ask whether the personis still experiencing symptoms for which medicineswere srcinally prescribed, e.g. constipation, depression,pain, gastro-oesophageal re 󿬂 ux, angina, insomnia, anxi-ety. If the person is no longer troubled by speci 󿬁 csymptoms, ask whether they wish to trial withdrawalof the relevant symptom-relieving medicine. In peoplewith dementia who are unable to report on symptomsand medicine side-effects, ask caregivers and inspectthe residential facility records to obtain the informationfor Residential Medication Management Reviews(RMMRs). Step Three: Write a Medicine Withdrawal Plan A medicine withdrawal plan is a list of all the medicinesthat will be deprescribed, the order in which they will be withdrawn, a plan for dose-tapering if required, andreminders about possible adverse withdrawal reactionsand/or symptom recurrence.1  Decide which medicines to cease Test each medicine against four criteria to determinewhether or not it should be deprescribed (Figure 1).Criterion One. Is the medicine inappropriately pre-scribed?a No valid indication (e.g. regular low-doseaspirin in someone with no established cardio-vascular disease) b An active contraindication or relative currentcontraindication (e.g. thiazide diuretic in some-one with gout)c Cascade prescribing - a medicine started tocombat the side-effects of another medicine. If the offending medicine can be withdrawn, itmay also be possible to withdraw the cascademedicine (e.g. laxatives in someone taking acalcium channel blocker).Criterion Two. Is the medicine having any adverseeffects or interactions (e.g. nose bleeds in someone tak-ing anticoagulants; iron de 󿬁 ciency anaemia in some-one taking a regular nonsteroidal anti-in 󿬂 ammatorydrug; diarrhoea in someone taking laxatives)?Criterion Three. Is the medicine intended for symp-tom relief and symptoms are stable or resolved (e.g.anti-anginal medicines in someone with stable ang-ina who is no longer physically active; anticholiner-gic treatments for urge incontinence in a personwho is immobile and being managed with an adultcontinence aid)?Criterion Four. Is the medicine intended to preventserious future events? If so:a Do adverse medicine effects outweigh anypotential future bene 󿬁 ts (e.g. aspirin for sec-ondary prevention causing gastrointestinal blood loss and/or nose bleeds)? b Does the person have a very short life-expec-tancy or such low quality of life that the poten-tial bene 󿬁 ts of the medicine are unlikely to berealised or that prolonging survival is no longera relevant objective (e.g. bisphosphonates, oralhypoglycaemics, aspirin, or statins in someonewith advanced dementia who is bed-boundwith no verbal communication)?If any of the above criteria are met, list the medicinefor deprescribing.2  Determine withdrawal order The  󿬁 rst group of medicines to stop are those that donot provide symptomatic bene 󿬁 t and do not need dosetapering as the risk of an adverse withdrawal reaction is ©  2016 The Society of Hospital Pharmacists of Australia  Journal of Pharmacy Practice and Research  (2016)  46,  358 – 367Deprescribing: a guide for medication reviews  359  low (i.e. bisphosphonates, aspirin, anticoagulants, sta-tins, and vitamin and mineral supplements). Thesemedicines can often be stopped simultaneously as thechance of an adverse withdrawal effect is very low.The second group to stop are medicines that arecontraindicated, not indicated, or causing adverse effectsAND need dose tapering due to the risk of adverse with-drawal effects or rebound symptoms if stopped abruptly(i.e. anti-re 󿬂 ux medicines, antihypertensives, antidepres-sants, antipsychotics, inhaled and oral steroids, long-act-ing beta-agonists, hypnotics, anxiolytics). Plan a taperingregime for these medicines based on their pharmacokinet-ics, particularly the half-life of elimination. These medici-nes should be stopped sequentially rather thansimultaneously unless you are certain that any potentialadverse withdrawal reactions or symptom recurrence will be attributable to a speci 󿬁 c medicine. For instance, anal-gesia should not be withdrawn at the same time as anantihypertensive agent in a person with dementia, as anysubsequent increase in blood pressure could be due toincreased pain or to rebound hypertension. Similarly,where people are on multiple antihypertensives, taperand withdraw one medicine at a time, starting with theagent causing the most signi 󿬁 cant side effects or thatoffers the fewest additional bene 󿬁 ts. For example, in aperson taking an ACE inhibitor, a beta-blocker, a diuretic,and a calcium channel blocker who has atrial  󿬁  brillation,ankle swelling, constipation, and postural hypotension, itwould be sensible to trial cessation of the calcium channel blocker  󿬁 rst. The decision about which antihypertensiveto cease next, assuming the blood pressure remained low,would depend on whether the person was taking anotheragent intended to control rate such as digoxin andwhether the ankle swelling resolved when the calciumchannel blocker was stopped.The  󿬁 nal group of medicines to stop are thoseintended for symptom relief where symptoms are stableor resolved or where the medicine was cascade-pre-scribed and the culprit medicine has been ceased (e.g.analgesics, laxatives, emollients, diuretics, lubricatingeye drops). These medicines should be stopped sequen-tially and in a logical order, i.e. stop opioid analgesics Withdrawal symptoms or disease recurrence likely if medicine ceased?  YESYESYES CEASEMEDICINE Taper dose and monitor for adverse withdrawal effects RESTART MEDICINE YESNOYESNO Symptoms stable?  YESNO CONTINUE MEDICINE1.Inappropriate prescription No clear indicationfor medicineor obvious contraindicationor cascade prescribing?  2.Adverse effects or interaction  Adverse effects or interactions outweigh symptomatic effect or  potential future benefits? 3.Medicine for symptom relief  Symptoms resolved or stable? 4.Medicine intended to prevent future serious events Significant adverse effects OR potential benefit unlikely to be realised due limited life expectancy?  NONONO Figure 1  Deprescribing algorithm.  Journal of Pharmacy Practice and Research  (2016)  46,  358 – 367  ©  2016 The Society of Hospital Pharmacists of Australia 360  K. Potter  et al.   before stopping laxatives, anticholinergic medicines before lubricating eye drops.3  Discuss the plan with your patient Discuss the medicine withdrawal plan with your patientand/or their primary carer and explain the rationale forstopping each of the medicines you have listed. Ensure theperson is willing to cease or trial cessation of each of themedicines and that they consent to the withdrawal pro-cess. Explain that they will be monitored carefully for anyadverse withdrawal effects during the deprescribing pro-cess and that if their symptoms recur, the medicine will berestarted or an alternative intervention provided.A written deprescribing plan is a useful tool, as itencourages the deprescriber to think clearly about whichmedicines are useful and important in a particular per-son and which medicines are not. It also helps withplanning a logical withdrawal order and anticipatingpossible adverse medicine withdrawal effects. An exam-ple of a medicine withdrawal plan is provided in theCase History. Guides for deprescribing speci 󿬁 c medici-nes are referenced in Table 1.Deprescribing in practice is more often pragmaticthan by the book. People frequently have their own pri-orities and these may not match the priorities of theirdeprescriber  –   for example, we may think it importantand urgent to taper and stop a long-acting benzodi-azepine in a person who is falling, but they may bemore bothered by an irritating cough from their ACE-inhibitor. Accommodating the person ’ s preferences andeliminating the medicines that they perceive as trouble-some or unnecessary will help keep them engaged sothat the maximum number of medicines can eventually be ceased. Ideally the deprescribing plan should bedeveloped in a co-operative process between the patient,their general practitioner and their community pharma-cist. For people who are in residential care, this processwill also require communication with the nurse managerand the patient ’ s family members. Step Four: Stop the Medicines When stopping a medicine, record when and why themedicine was stopped in all the patient ’ s notes (residen-tial care facility, general practice, pharmacy). This willreduce the risk of another prescriber restarting a medi-cine because they think it has been stopped in error. Forpeople in residential care, the dispensing pharmacistshould be informed that a medicine has been stoppedand deprescribed medicines should be deleted from thedrug chart to prevent continued administration. Formedicines that require dose tapering, instruct thepatient, the primary caregiver, and/or the dispensingpharmacist to halve or quarter tablets or go to second-day or third-day dosing, depending on the formulationand half-life of the drug. This reduces the requirementfor new prescriptions and additional dispensing andalso reduces the risk of dosing errors. When medicineswith a high likelihood of transient or prolongedrebound symptoms (e.g. proton-pump inhibitors, benzo-diazepines) or symptom recurrence (e.g. analgesics, laxa-tives) are deprescribed, ensure that on-demand doses of the withdrawn medicine are available. The frequencywith which the on-demand medicine is used will indi-cate the severity and duration of the withdrawal symp-toms and help you assess whether the medicine needsto be re-prescribed as a regular medicine. Step Five: Monitoring and Follow-Up The withdrawal process should be cautious with regularmonitoring of the patient for adverse withdrawal effectsand symptom recurrence. The optimum frequency of monitoring depends on the medicine being withdrawn.It is important to tell carers of people with moderateand advanced dementia about speci 󿬁 c signs that mayindicate symptom recurrence, e.g. reduced oral intakeand/or weight loss after cessation of an anti-re 󿬂 ux medi-cine; abdominal discomfort, agitation and reduced bowel motion frequency after cessation of a laxative. Itis also important to be aware of delayed symptomrecurrence when medicines with a long half-life areceased, e.g. amiodarone, digoxin, dutasteride, donepezil, 󿬂 uoxetine. CONCLUSIONS The central activity in deprescribing is the cessation of medicines. The simple part of deprescribing is crossingmedicines off a drug chart or deleting them from pre-scribing software. The hard part is ensuring that thepatient actually bene 󿬁 ts from the process. The depre-scribing process described above is based on a researchintervention, but the principles apply in clinical practicewhether deprescribing is initiated by a geriatrician, ageneral practitioner, or a consultant pharmacist con-ducting a medication review. The take-home message isthat quality deprescribing must be individualised forthe speci 󿬁 c person and requires knowledge of theirmedical history, their current level of function, and theirpreferences and expectations. This type of understand-ing can only be achieved with co-operation and clearcommunication between the patient, their family and/orcarers, and the key health professionals involved intheir care. ©  2016 The Society of Hospital Pharmacists of Australia  Journal of Pharmacy Practice and Research  (2016)  46,  358 – 367Deprescribing: a guide for medication reviews  361  Table 1  Deprescribing resourcesLink Author/organisation Description Dr. Barbara Farrell andDr. Cara TannenbaumCanadian Deprescribing Network(CaDeN)A website with tools to help patients and providersparticipate in deprescribing, including deprescribingalgorithms, deprescribing information pamphlets andpatient decision aids. Brochures for deprescribingsedative-hypnotic, proton pump inhibitor, sulfonylurea,antipsychotic and antihistamine medicines. Also adviceabout non-pharmacological management of insomnia. resources/deprescribingPrimary Health Tasmania (a non-government, not-for-pro 󿬁 torganisation working to keepTasmanians well and out of hospital)Downloadable fact sheets on deprescribing speci 󿬁 cclasses of medicine including vitamin D and calcium,sulphonylureas, statins, proton pump inhibitors,opioids, NSAIDs, glaucoma eye drops, cholinesteraseinhibitors, bisphosphonates, benzodiazepines,antipsychotics, antiplatelets, antihypertensives andallopurinol. Also consumer brochures and a quickreference guide for deprescribers. MedicinesManagement/ Guidelines/StopstartToolkit2011.pdf Medicines Management TeamNational Health Service CumbriaA printable guide to assist with applying the STOPPSTART criteria in practice. Colour-coded with red forstopping potentially inappropriate medicines and greenfor starting indicated medicines in people aged over65 years. Medicines sorted by system rather than drugclass, i.e. gastrointestinal, cardiovascular, respiratory,nervous, endocrine, urogenital, musculoskeletal andmiscellaneous. April/stopguide.aspxBest Practice Advocacy CentreNew Zealand (an independent,not-for-pro 󿬁 t organisation thatdelivers educational andcontinuing professionaldevelopment programs to healthpractitioners throughout NewZealand)A practical guide to stopping medicines in older people,including simple-to-follow advice that will help you todetermine which medicines can be stopped, the likelyconsequences of stopping medicines and guidance onhow to stop speci 󿬁 c medicines, includingantidepressants, benzodiazepines, antihypertensives,statins, warfarin, NSAIDS, acid suppressants, bisphosphonates, oral corticosteroids, antiparkinsonagents. December/medication-list/ Sarah N. Hilmer, Danijela Gnjidic,David G. Le CouteurArticle on deprescribing including a review of evidence forsafety and ef  󿬁 cacy of common medicines in older people,speci 󿬁 cally statins, bisphosphonates, antiplatelet andantithrombotic agents, antihypertensives, sulfonylureasand antibiotics. ages-life-stages/for-individuals/ older-people-and-medicinesNPS MedicineWise is anindependent organisation funded by the Australian Department of Health that aims to improvequality use of medicines byproviding health professionalsand consumer information tosupport good prescribing anddecisions about medicinesIndependent health and treatment information aboutmedicines safety in older people (including side effectsand health issues with taking multiple medicines) written by Australian experts. This includes resources forconsumers and health professionals. James McCormack, Dee Mangin,Barb Farrell, John Sloan, JohannaTrimble, Mike Allan, RitaMcCracken, Keith White, RobertRangnoAn online tool to help clinicians and patients makedecisions about reducing or stopping medications. Themedication list is entered and Medstopper sequences thedrugs from  ‘ more likely to stop ’  to  ‘ less likely to stop ’  , based on three key criteria: the potential of the drug toimprove symptoms, its potential to reduce the risk of future illness and its likelihood of causing harm.Suggestions for how to taper medicines are also provided.NSAIDs  =  non-steroidal anti-in 󿬂 ammatory drugs.  Journal of Pharmacy Practice and Research  (2016)  46,  358 – 367  ©  2016 The Society of Hospital Pharmacists of Australia 362  K. Potter  et al.
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