A recent study
relating inappropriate prescribing to hospital admission has highlighted the
need for a focus on deprescribing. Perez and colleagues (Perez 2018)
looked at the prevalence of potentially inappropriate prescribing assessed
using 45 criteria from the Screening Tool for Older Persons’ Prescription
(STOPP) in adults aged 65 years or over in 44 general practices in Ireland. The
overall prevalence of potentially inappropriate prescribing ranged from 45.3%
to 51.0%. After adjustment for multiple factors, hospital admission was independently
associated with a higher rate of distinct potentially inappropriate prescribing
criteria met (adjusted hazard ratio 1.24). Moreover, among participants who
were admitted to hospital, the likelihood of potentially inappropriate
prescribing after admission was even higher than before admission (adjusted
odds ratio 1.72).
The accompanying editorial (Avery 2018)
points out that there are opportunities to identify inappropriate prescribing
both at hospital admission and at the outpatient followup
visit after hospital discharge. It notes several factors that are barriers.
Many hospital-based physicians may be reluctant to discontinue medications
started by someone else. And the fact that many hospital-based physicians do
not participate in post-hospital outpatient care is another factor. Another
factor is that additional comorbidities often lead to potentially inappropriate
prescribing. Communication between outpatient and inpatient physicians is
clearly important. The editorialists also note that effective mulltidisciplinary working, involvement of pharmacists, and
use of electronic health records for identifying patients at risk and providing
decision support are important in the deprescribing process.
One category of medications on most “inappropriate” lists
is high‐risk anticholinergics.
This category includes medications such as antidepressants, antimuscarinics,
and antihistamines that may have significant anticholinergic side effects.
However, despite concern over negative outcomes associated with these drugs in
older adults, researchers found that the overall prescribing trends of these
medications remained largely unchanged between 2006 and 2015 (Rhee
2018).
While we usually
refer to inappropriate prescribing for a population, such as those age 65 and
older, don’t forget that there is also inappropriate prescribing based upon
certain conditions a patient may have. The classic one is Parkinson’s Disease (see our prior columns for August 2011 “Problems Managing Medications in Parkinson’s
Disease”, December 2012 “More
on Hospitalized Parkinson’s Disease Patients”,
and June 2015 “More
Risks for Parkinson Inpatients”). A new study (Mantri 2018) looked at patterns of dementia treatment
and frank prescribing errors in older adults with Parkinson Disease. 27.2% were
given a prescription for at least 1 antidementia medication. Of those receiving
an acetylcholinesterase inhibitor (ACHEI), 44.5% experienced at least 1
high-potency anticholinergic–ACHEI event. They did find variation in such
prescribing by race/ethnicity, sex, and geography.
Don’t forget that
deprescribing should also consider medications intended only for short term
use. The classic examples are PPI’s
(proton pump inhibitors) that were begun while a patient was in the ICU and
never discontinued. While good medication reconciliation done at both transfer
out of the ICU and at hospital discharge should catch the error of continuing
PPI’s, these are commonly missed and patients continue
on them. Then, at the first primary care visit following discharge, physicians
may not question the indication for continued use of the PPI’s and simply continue
to renew prescriptions for them. PPI’s did make the most recent update of Beers’
Criteria (American Geriatrics Society 2015).
For many years,
drugs reducing gastric acid secretion were felt to benefit patients in ICU
settings who are considered at risk for the development of stress ulceration
and bleeding. But even that premise has been challenged recently. Krag and colleagues (Krag 2018) randomized ICU patients who were at risk
for gastrointestinal bleeding to intravenous pantoprazole (a proton-pump
inhibitor) or placebo. They found that mortality at 90 days and the number of
clinically important events were similar in those assigned to pantoprazole and
those assigned to placebo.
Whether the Krag study will change use of PPI’s in the ICU or not, it’s
important for us to recognize when PPI’s are continued beyond their intended
duration. In fact, a new name has been given to such practice: "legacy prescribing" refers to the
prescribing of drugs for a longer period than is typically needed to treat a
condition.
Canadian researchers (Mangin
2018) noted that commonly prescribed drugs with
legacy prescribing potential include antidepressants, bisphosphonates, and
proton pump inhibitors (PPIs), so they evaluated the proportion of legacy
prescribing within these drug classes. Using a large population-based database,
they calculated rates of legacy prescribing of antidepressants (prescription
longer than 15 months), bisphosphonates (longer than 5.5 years), and PPIs
(longer than 15 months). The proportion of patients having a legacy
prescription at some time during the study period was 46% for antidepressants,
14% for bisphosphonates, and 45% for PPIs. The mean duration of prescribing for
all legacy prescriptions was significantly longer than that for non–legacy
prescriptions. Concurrent legacy prescriptions for both antidepressants and
PPIs was common, which the authors suspect may signal a potential prescribing
cascade (that is, side effects of one potentially inappropriate medication may
lead to prescription of a second potentially inappropriate medication).
Bytzer
(Bytzer 2018) noted prescribing of PPIs increased
fourfold in Denmark over the last decade, with the increase particularly marked
among older patients. 7% of all adults and 14% of adults over 60 were covered
by PPI prescriptions. The increased prescribing of PPIs was driven primarily by
the accumulation of existing users rather than by new users; inappropriate
prescribing and long term use, rather than genuine clinical
need for ulcer prophylaxis, appear to underlie the high prevalence of PPI
prescribing.
One of the unintended consequences of
healthcare information technology may contribute to “legacy” prescribing. In
our May 27, 2014 Patient Safety Tip of the Week “A Gap
in ePrescribing: Stopping Medications” and
our March 2017 What's New in the Patient Safety World column “Yes! Another Voice for Medication e-Discontinuation!”
we highlighted what we consider to be a
major flaw in current e-prescribing systems, namely that they do not put the
same emphasis on stopping medications as they do on starting them.
Yet another factor
contributing to “legacy” prescribing is the fact that most of our systems do
not include any way to input the original indication
for a medication. Some medications, most notably beta-blockers, have numerous
potential indications. Having access to the reason a medication was originally
started may help in both the medication reconciliation process and the
deprescribing process. For example, if a physician could see a PPI was ordered “for
prophylaxis while in the ICU”, it would be easy to see it should no longer be continued
after discharge from the ICU.
Ironically,
healthcare IT should be a potential solution to the problems of both
inappropriate prescribing and legacy prescribing. Good clinical decision
support systems should be able to alert clinicians to potentially inappropriate
medications any time a clinician utilizes a CPOE or e-prescribing system. And
they should flag medications that are usually intended for short courses that
appear to be prescribed for longer periods.
So that gets us to
the deprescribing process. Results of the D-PRESCRIBE (Developing
Pharmacist-Led Research to Educate and Sensitize Community Residents to the
Inappropriate Prescriptions Burden in the Elderly) trial were recently
published (Martin 2018). That studied the effectiveness of a
consumer-targeted, pharmacist-led educational intervention vs usual care on
discontinuation of inappropriate medication among community-dwelling older
adults in Quebec. They included patients prescribed 1 of 4 Beers Criteria
medications (sedative-hypnotics, first-generation antihistamines, glyburide, or
nonsteroidal anti-inflammatory drugs), At 6 months, 43% in the intervention
group no longer filled prescriptions for inappropriate medication compared with
12% in the control group.
In the intervention
vs control group, discontinuation of inappropriate medication occurred in 43.2%
vs. 9.0% for sedative-hypnotic drug users, 30.6% vs. 13.8% for glyburide, and 57.6%
vs. 21.7% for nonsteroidal anti-inflammatory drugs.
Importantly, no
adverse events requiring hospitalization were reported, although 29 of 77
patients (38%) who attempted to taper sedative-hypnotics reported withdrawal
symptoms. The latter statistic reminds us that many medications should not
simply be discontinued all at once. Fortunately, there are evidence-based
algorithms available for deprescribing many medications. One website, deprescribing.org, has links to algorithms for deprescribing
several drugs, including PPI’s, benzodiazepine receptor agonists,
antipsychotics, cholinesterase inhibitors and memantine, and
antihyperglycemics. In addition to the algorithm for deprescribing PPI’s
available on that website, there is also a toolkit for deprescribing PPI’s on
the Choosing Wisely Canada website (Wintemute 2017).
In our October 31, 2017 Patient Safety Tip of
the Week “Target Drugs for Deprescribing” we
noted Douglas Paauw’s “11 Drugs You Should
Seriously Consider Deprescribing”. His list has recently been updated (Paauw 2018)
and is a good place to start when you begin your deprescribing programs:
But don’t forget
that, in our desire to minimize polypharmacy, we also need to focus on medications
that patients should be taking (for their comorbidities). We addressed
“optimizing” medications in our October 19, 2010 Patient Safety Tip of the Week
“Optimizing Medications in the Elderly”. While you are focusing on deprescribing,
that is also an opportunity to determine whether patients are missing
medications they should be taking.
Some of our past
columns on deprescribing:
Some of our past
columns on Beers’ List and
Inappropriate Prescribing in the Elderly:
References:
Perez T, Moriarty
F, Wallace E, et al. Prevalence of potentially inappropriate prescribing in
older people in primary care and its association with hospital admission:
longitudinal study. BMJ 2018; 363 Published 14 November 2018
https://www.bmj.com/content/363/bmj.k4524
Avery AJ, Coleman
JJ. Tackling potentially inappropriate prescribing (editorial). BMJ 2018;
363 Published 14 November 2018
https://www.bmj.com/content/363/bmj.k4688
Rhee TG, Choi YC,
Ouellet GM, Ross JS. National Prescribing Trends for High‐Risk
Anticholinergic Medications in Older Adults. J Am Geriatr
Soc 2018; 66(7): 1382-1387
https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15357
Mantri S, Fullard M, Gray SL, et al. Patterns of Dementia Treatment
and Frank Prescribing Errors in Older Adults With
Parkinson Disease. JAMA Neurol 2018; Published online October 1, 2018
https://jamanetwork.com/journals/jamaneurology/article-abstract/2704469
American Geriatrics
Society. American Geriatrics Society 2015 Updated Beers Criteria for
Potentially Inappropriate Medication Use in Older Adults. J Amer Geriat Soc 2015; 63(11): 2227-2246 Article first published
online 8 Oct 2015
https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.13702
Krag
M, Marker S, Perner A, et al. Pantoprazole in
patients at risk for gastrointestinal bleeding in the ICU. N Engl J Med 2018; Published online October 24, 2018
https://www.nejm.org/doi/full/10.1056/NEJMoa1714919
Mangin
D, Lawson J, Cuppage, J, et al. Legacy
Drug-Prescribing Patterns in Primary Care. Ann Fam Med 2018; 16(6): 515-520
http://www.annfammed.org/content/16/6/515.full
Bytzer
P. Deprescribing proton pump inhibitors: why, when and how. Med J Aust 2018;
209(10): 436-438
https://www.mja.com.au/journal/2018/209/10/deprescribing-proton-pump-inhibitors-why-when-and-how
Martin P, Tamblyn
R, Benedetti A, et al. Effect of a Pharmacist-Led Educational Intervention on
Inappropriate Medication Prescriptions in Older AdultsThe
D-PRESCRIBE Randomized Clinical Trial. JAMA 2018; 320(18): 1889-1898
https://jamanetwork.com/journals/jama/article-abstract/2714531
Deprescribing.org
Wintemute K. Bye,
bye, PPI: a toolkit for deprescribing proton pump inhibitors in EMR-enabled
primary care settings. Version 1.2. Toronto, Ontario: Choosing Wisely Canada;
July 2017.
https://choosingwiselycanada.org/wp-content/uploads/2017/07/CWC_PPI_Toolkit_v1.2_2017-07-12.pdf
Paauw
DS. 11 Drugs You Should Seriously Consider Deprescribing: 2018 Update. Medscape
2018; November 5, 2018
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