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:
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
Avery AJ, Coleman JJ. Tackling potentially inappropriate prescribing (editorial). BMJ 2018; 363 Published 14 November 2018
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
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
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
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
Mangin D, Lawson J, Cuppage, J, et al. Legacy Drug-Prescribing Patterns in Primary Care. Ann Fam Med 2018; 16(6): 515-520
Bytzer P. Deprescribing proton pump inhibitors: why, when and how. Med J Aust 2018; 209(10): 436-438
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
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.
Paauw DS. 11 Drugs You Should Seriously Consider Deprescribing: 2018 Update. Medscape 2018; November 5, 2018
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