Deprescribing

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Reduce medication burden and harm VariousPills.jpg
Reduce medication burden and harm

Deprescribing is a process of tapering or stopping medications to achieve improved health outcomes by reducing exposure to medications that are potentially either harmful or no longer required. [1] Deprescribing is important to consider with changing health and care goals over time, as well as polypharmacy and adverse effects. [2] Deprescribing can improve adherence, cost, and health outcomes but may have adverse drug withdrawal effects. More specifically, deprescribing is the planned and supervised 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. [3] [4] Deprescribing can help correct polypharmacy and prescription cascade.

Contents

Deprescribing is often done with people who have multiple long-term conditions (multimorbidity), older people, and people who have a limited life expectancy. [5] 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. Deprescribing aims 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." [6]

The process of deprescribing is usually planned and supervised by healthcare professionals. [7] To some, the definition of deprescribing includes only completely stopping a medication, while to others, deprescribing also includes dose reduction, which can improve quality of life (minimize side effects) while maintaining benefits. [8]

History

The world’s first published use of the term “deprescribing” was described in 2003 by Michael Woodward in his article titled ‘Deprescribing: Achieving Better Health Outcomes for Older People through Reducing Medications.' It was published in the Society of Hospital Pharmacists of Australia's flagship Journal of Pharmacy Practice and Research (JPPR).’ [9] [ additional citation(s) needed ]

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,[ better source needed ] and mortality. [10] These effects are particularly seen in high-risk prescribing. [11] Thus, optimizing medication through targeted deprescribing is a vital part of managing chronic conditions, avoiding adverse effects and improving outcomes.

Evidence base

Deprescribing is considered a potential intervention with reported safety and feasibility. [12] [13] For a wide range of medications, including diuretics, blood pressure medication, sedatives, antidepressants, benzodiazepines and nitrates, adverse effects of deprescribing are rare. [14] [15] While deprescribing has been shown to result in fewer medications, it is less certain if deprescribing is associated with significant changes in health outcomes. [12] [16] Although it might be possible and safe to reduce the number of medicines that people use, reversing the potential harms associated with polypharmacy may not always be achievable. Early evidence suggested that deprescribing may reduce premature death, leading to calls to undertake a double-blind study. A placebo-controlled, double-blind, randomized controlled trial was published in 2023. This study undertook deprescribing in people over 65 years living in residential aged care. [17] It found no change in mortality [18] and that, if implemented in all residential aged care facilities across Australia, it could save up to $16 million annually. [19]

Deprescribing medications may 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 people experience but not to change the risk of having the first fall. [12] Most health outcomes remain unchanged as an effect of deprescribing. The absence of 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 due to deprescribing. [12]

Targeted deprescribing can improve adherence to other drugs. [5] Deprescribing can reduce the complexity of medication schedules. Complicated schedules are difficult for people to follow correctly.

The product information provided by drug companies provides much information on how to start medications and what to expect when using them. However, it provides little information on when and how to stop medications. [20] Research into deprescribing is accumulating, with two papers showing a rapid acceleration in using the word since 2015. [8] [3]

In people with multiple long-term conditions and polypharmacy, deprescribing represents a complex challenge as clinical guidelines are usually developed for single conditions. In these cases, tools and guidelines like the Beers Criteria and STOPP/START could be used safely by clinicians, but not all patients might benefit from stopping their medication. There is a need for clarity about how much clinicians can do beyond the guidelines and the responsibility they need to take could help them prescribing and deprescribing for complex cases. Further factors that can help clinicians tailor their decisions to the individual are: access to detailed data on the people in their care (including their backgrounds and personal medical goals), discussing plans to stop a medicine already when it is first prescribed, and a good relationship that involves mutual trust and regular discussions on progress. Furthermore, longer appointments for prescribing and deprescribing would allow time to explain the process, explore related concerns, and support making the right decisions. [21] [22]

Risks

It is possible for the patient to develop adverse drug withdrawal events (ADWE). [23] These symptoms may be related to the original reason why the medication was prescribed, to withdrawal symptoms or to underlying diseases that medications have masked. [24] 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. [15] The recommended schedule for monitoring during deprescribing is at two-week intervals. [25]

Resources to support deprescribing

Implicit tools

Several tools have been published to inform prescribers of inappropriate medications for various patient groups. The most common deprescribing algorithm is validated [26] and has been tested in two RCTs. [16] It is available for clinicians to identify medications that can be deprescribed. [26] It prompts clinicians to consider if it is (1) an inappropriate prescription, (2) adverse effects or interactions that outweigh symptomatic effects or potential future benefits, (3) drugs taken for symptom relief but the symptoms are stable, and (4) drug intended to prevent future severe events but the potential benefit is unlikely to be realized due to limited life expectancy. If the answer to any of the four prompts is yes, then the medication should be considered for deprescribing.

The CEASE algorithm prompts clinicians to consider if the treated condition remains a current concern for their patient.

The ERASE algorithm prompts clinicians to consider whether the treated condition still requires treatment. [27] The ERASE mnemonic stands for "evaluate diagnostic parameters," "resolved conditions," "ageing normally," "select targets," and "eliminate."

Explicit tools

The Beers Criteria and the STOPP/START criteria present medications that may be inappropriate for use in older adults, [28] including drugs associated with high risk of adverse reactions for this population or lacking evidence for their benefits when safer and more effective alternatives exist. [29] Some countries, such as, Australia have their lists of Potentially Inappropriate Medicines. [30] For people with dementia, the Medication Appropriateness Tool for Comorbid Health Conditions in Dementia (MATCH-D) [31] can help clinicians identify when and what to consider deprescribing. [32]

Resources

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. [33] Tasmanian Medicare Local has created resources to help clinicians deprescribe. [34] Theoretical Underpinnings of a Model to Reduce Polypharmacy and Its Negative Health Effects: Introducing the Team Approach to Polypharmacy Evaluation and Reduction (TAPER) is a framework to support practitioners in deprescribing. [35]

Practice changes to encourage deprescribing

An expert working group concluded that integrated healthcare provided by multidisciplinary patient-centred teams was the most appropriate approach to promote deprescribing and improve appropriate medication use. [36] Deprescribing rounds in tertiary care hospitals have also been evaluated and shown to improve health-related outcomes. [37]

Barriers and enablers to deprescribing

Barriers

Although many trials have successfully resulted in a reduction in medication use, there are some barriers to deprescribing:

Enablers

The prescriber and patients were shown to have the most significant influence on each other rather than external influences. 9 out of 10 older people said they would be willing to stop one or more medications if their doctor said it was okay.

See also

Related Research Articles

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Pharmacy is the science and practice of discovering, producing, preparing, dispensing, reviewing and monitoring medications, aiming to ensure the safe, effective, and affordable use of medicines. It is a miscellaneous science as it links health sciences with pharmaceutical sciences and natural sciences. The professional practice is becoming more clinically oriented as most of the drugs are now manufactured by pharmaceutical industries. Based on the setting, pharmacy practice is either classified as community or institutional pharmacy. Providing direct patient care in the community of institutional pharmacies is considered clinical pharmacy.

<span class="mw-page-title-main">Geriatrics</span> Specialty that focuses on health care of elderly people

Geriatrics, or geriatric medicine, is a medical specialty focused on providing care for the unique health needs of the elderly. The term geriatrics originates from the Greek γέρων geron meaning "old man", and ιατρός iatros meaning "healer". It aims to promote health by preventing, diagnosing and treating disease in older adults. There is no defined age at which patients may be under the care of a geriatrician, or geriatric physician, a physician who specializes in the care of older people. Rather, this decision is guided by individual patient need and the caregiving structures available to them. This care may benefit those who are managing multiple chronic conditions or experiencing significant age-related complications that threaten quality of daily life. Geriatric care may be indicated if caregiving responsibilities become increasingly stressful or medically complex for family and caregivers to manage independently.

A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

The Pharmaceutical Benefits Scheme (PBS) is a program of the Australian Government that subsidises prescription medication for Australian citizens and permanent residents, as well as international visitors covered by a reciprocal health care agreement. The PBS is separate to the Medicare Benefits Schedule, a list of health care services that can be claimed under Medicare, Australia's universal health care insurance scheme.

<span class="mw-page-title-main">Pharmacogenomics</span> Study of the role of the genome in drug response

Pharmacogenomics, often abbreviated "PGx," is the study of the role of the genome in drug response. Its name reflects its combining of pharmacology and genomics. Pharmacogenomics analyzes how the genetic makeup of a patient affects their response to drugs. It deals with the influence of acquired and inherited genetic variation on drug response, by correlating DNA mutations with pharmacokinetic, pharmacodynamic, and/or immunogenic endpoints.

<span class="mw-page-title-main">Polypharmacy</span> Use of five or more medications daily

Polypharmacy (polypragmasia) is an umbrella term to describe the simultaneous use of multiple medicines by a patient for their conditions. The term polypharmacy is often defined as regularly taking five or more medicines but there is no standard definition and the term has also been used in the context of when a person is prescribed 2 or more medications at the same time. Polypharmacy may be the consequence of having multiple long-term conditions, also known as multimorbidity and is more common in people who are older. In some cases, an excessive number of medications at the same time is worrisome, especially for people who are older with many chronic health conditions, because this increases the risk of an adverse event in that population. In many cases, polypharmacy cannot be avoided, but 'appropriate polypharmacy' practices are encouraged to decrease the risk of adverse effects. Appropriate polypharmacy is defined as the practice of prescribing for a person who has multiple conditions or complex health needs by ensuring that medications prescribed are optimized and follow 'best evidence' practices.

<span class="mw-page-title-main">Adverse drug reaction</span> Harmful, unintended result of medication

An adverse drug reaction (ADR) is a harmful, unintended result caused by taking medication. ADRs may occur following a single dose or prolonged administration of a drug or may result from the combination of two or more drugs. The meaning of this term differs from the term "side effect" because side effects can be beneficial as well as detrimental. The study of ADRs is the concern of the field known as pharmacovigilance. An adverse event (AE) refers to any unexpected and inappropriate occurrence at the time a drug is used, whether or not the event is associated with the administration of the drug. An ADR is a special type of AE in which a causative relationship can be shown. ADRs are only one type of medication-related harm. Another type of medication-related harm type includes not taking prescribed medications, known as non-adherence. Non-adherence to medications can lead to death and other negative outcomes. Adverse drug reactions require the use of a medication.

An adverse effect is an undesired harmful effect resulting from a medication or other intervention, such as surgery. An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. The term complication is similar to adverse effect, but the latter is typically used in pharmacological contexts, or when the negative effect is expected or common. If the negative effect results from an unsuitable or incorrect dosage or procedure, this is called a medical error and not an adverse effect. Adverse effects are sometimes referred to as "iatrogenic" because they are generated by a physician/treatment. Some adverse effects occur only when starting, increasing or discontinuing a treatment. Using a drug or other medical intervention which is contraindicated may increase the risk of adverse effects. Adverse effects may cause complications of a disease or procedure and negatively affect its prognosis. They may also lead to non-compliance with a treatment regimen. Adverse effects of medical treatment resulted in 142,000 deaths in 2013 up from 94,000 deaths in 1990 globally.

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The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, commonly called the Beers List, are guidelines published by the American Geriatrics Society (AGS) for healthcare professionals to help improve the safety of prescribing medications for adults 65 years and older in all except palliative settings. They emphasize deprescribing medications that are unnecessary, which helps to reduce the problems of polypharmacy, drug interactions, and adverse drug reactions, thereby improving the risk–benefit ratio of medication regimens in at-risk people.

Multimorbidity, also known as multiple long-term conditions (MLTC), means living with two or more chronic illnesses. For example, a person could have diabetes, heart disease and depression at the same time. Multimorbidity can have a significant impact on people's health and wellbeing. It also poses a complex challenge to healthcare systems which are traditionally focused on individual diseases. Multiple long-term conditions can affect people of any age, but they are more common in older age, affecting more than half of people over 65 years old.

<span class="mw-page-title-main">Hospital pharmacy</span> Dispensary within a hospital

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Prescription cascade is the process whereby the side effects of drugs are misdiagnosed as symptoms of another problem, resulting in further prescriptions and further side effects and unanticipated drug interactions, which itself may lead to further symptoms and further misdiagnoses. This is a pharmacological example of a feedback loop. Such cascades can be reversed through deprescribing.

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<span class="mw-page-title-main">Drug utilization review</span>

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Cara Tannenbaum is a Canadian researcher and practicing physician in the fields of geriatrics, women's health and gender research. Since 2015, Tannenbaum has served as the Scientific Director of Canadian Institutes of Health Research's Institute of Gender and Health. She was appointed as a Member of the Order of Canada on November 17, 2021.

<span class="mw-page-title-main">Somnifacient</span> Class of medications that induce sleep

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References

  1. ↑ Page A, Clifford R, Potter K, Etherton-Beer C (April 2018). "A concept analysis of deprescribing medications in older people". Journal of Pharmacy Practice and Research. 48 (2): 132–148. doi: 10.1002/jppr.1361 . S2CID   56510472.
  2. ↑ Quek HW, Page A, Potter K, Etherton-Beer C (April 2023). "Deprescribing considerations for older people in general practice". Australian Journal of General Practice. 52 (4): 173–180. doi: 10.31128/AJGP-08-22-6547 . PMID   37021442. S2CID   257984022.
  3. 1 2 Reeve E, Gnjidic D, Long J, Hilmer S (December 2015). "A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice". British Journal of Clinical Pharmacology. 80 (6): 1254–1268. doi:10.1111/bcp.12732. PMC   4693477 . PMID   27006985.
  4. ↑ Thompson W, Farrell B (May 2013). "Deprescribing: what is it and what does the evidence tell us?". The Canadian Journal of Hospital Pharmacy. 66 (3): 201–202. doi:10.4212/cjhp.v66i3.1261. PMC   3694945 . PMID   23814291.
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  6. ↑ Linsky A, Simon SR (April 2013). "Reversing gears: discontinuing medication therapy to prevent adverse events". JAMA Internal Medicine. 173 (7): 524–525. doi:10.1001/jamainternmed.2013.4068. PMID   23459795.
  7. ↑ Liacos M, Page AT, Etherton-Beer C (August 2020). "Deprescribing in older people". Australian Prescriber. 43 (4): 114–120. doi:10.18773/austprescr.2020.033. PMC   7450772 . PMID   32921886.
  8. 1 2 Page A, Clifford R, Potter K, Etherton-Beer C (April 2018). "A concept analysis of deprescribing medications in older people". Journal of Pharmacy Practice and Research. 48 (2): 132–148. doi: 10.1002/jppr.1361 .
  9. ↑ Woodward MC (2003). "Deprescribing: Achieving Better Health Outcomes for Older People through Reducing Medications". Journal of Pharmacy Practice and Research. 33 (4). Wiley: 323–328. doi:10.1002/jppr2003334323. ISSN   1445-937X.
  10. ↑ Bloomfield, Hanna E.; Greer, Nancy; Linsky, Amy M.; Bolduc, Jennifer; Naidl, Todd; Vardeny, Orly; MacDonald, Roderick; McKenzie, Lauren; Wilt, Timothy J. (November 2020). "Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis". Journal of General Internal Medicine. 35 (11): 3323–3332. doi:10.1007/s11606-020-06089-2. ISSN   0884-8734. PMC   7661661 . PMID   32820421.
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