Patient Safety Tip of the Week
October 31, 2017 Target Drugs for Deprescribing
We’ve done numerous
columns on the use of potentially inappropriate medications (PIM’s) in the
elderly and the value of deprescribing (see list at
the end of today’s column). Two populations particularly vulnerable to PIM’s are:
(1) nursing home residents and (2) patients
with dementia. Two recent studies examined PIM’s in these populations.
Dutch researchers looked at the impact of deprescribing in a nursing home population in a randomized
trial (Wouters
2017). Potentially inappropriate medications (PIM’s) were identified
using several tools we’ve often discussed: START (Screening Tool to Alert Doctors
to Right Treatment), STOPP (Screening Tool of Older Persons' Potentially Inappropriate
Prescriptions), and the Beers criteria.
Patients were assigned to intervention with their Multidisciplinary
Multistep Medication Review (3MR) or to usual care. Components of the 3MR are:
- assessment of the
patient's perspective and a comprehensive medical and medication review
- pharmacist identification
of "potential overprescribing and underprescribing
and other suboptimal prescribing conditions"
- a meeting between the treating
physician and the pharmacist to review the medications and develop a
revised plan
- implementation of
medication changes on the basis of the plan
More patients discontinued use of at least 1 PIM in the
intervention group than the control group (39.1% vs. 29.5%) and clinical
outcomes did not deteriorate between baseline and follow-up.
Another European study (Renom-Guiteras
2017) found that 60% of the patients with dementia had at least one
PIM prescription and 26.4% at least two. The PIM therapeutic subgroups most
frequently prescribed were psycholeptics (26% of all
PIM prescriptions) and ‘drugs for acid-related disorders’ (21%). Prescription
of two or more PIM’s was associated with higher chance of suffering from at
least one fall-related injury and at least one episode of hospitalization in
the time between baseline and follow-up. Risk factors for being prescribed two
or more PIM’s were: age 80 years and older, living in institutional long-term
care settings, having more comorbidities, and having more functional
impairment.
Douglas Paauw, MD (Paauw
2017) recently discussed “11 Drugs You Should Seriously Consider Deprescribing”:
- Stool softeners
- Antibiotics before dental
procedures
- PPI’s
- Statins for primary
prevention in patients 75 y.o. or older
- Benzodiazepines/Z drugs
- Beta Blockers
- Drugs for Asthma/COPD
- Antimuscarinics
for urinary incontinence
- Cholinesterase inhibitors
for Alzheimer’s Disease
- Muscle relaxants for back
pain
- Supplements
Paauw also co-authored a recent
study on polypharmacy in primary care, focusing on medication side effects and
drug interactions (Merel 2017).
They discussed important side effects of several medications commonly
prescribed in older adults (statins, proton pump inhibitors,
trimethoprim-sulfamethoxazole and fluoroquinolone antibiotics, zolpidem,
nonsteroidal antiinflammatory drugs, selective
serotonin reuptake inhibitors, dipeptidyl peptidase 4
inhibitors). They also discussed important drug interactions with four agents
or classes (statins, warfarin, factor Xa inhibitors,
and calcium channel blockers).
These articles are important practical contributions to our
understanding of polypharmacy and our potential to reduce use of PIM’s. Deprescribing, when done properly, can be a very valuable
intervention to improve the lives of our elderly patients. We hope you’ll go
back and review some of our previous articles on deprescribing.
Some of our past columns on Beers’ List and Inappropriate
Prescribing in the Elderly:
- January 15, 2008 “Managing
Dangerous Medications in the Elderly
- June 2008 “Potentially
Inappropriate Medication Use in Elderly Hospitalized Patients”
- October 19, 2010 “Optimizing
Medications in the Elderly”
- September 22, 2009 “Psychotropic
Drugs and Falls in the SNF”
- September 2010 “Beers
List and CPOE”
- June 21, 2011 “STOPP
Using Beers’ List?”
- December 2011 “Beers’
Criteria Update in the Works”
- May 7, 2013 “Drug
Errors in the Home”
- November 12, 2013 “More
on Inappropriate Meds in the Elderly”
- January 28, 2014 “Is
Polypharmacy Always Bad?”
- March 4, 2014 “Evidence-Based
Prescribing and Deprescribing in the Elderly”
- September 30, 2014 “More
on Deprescribing”
- February 10, 2015 “The
Anticholinergic Burden and Dementia”
- May 2015 “Hospitalization:
Missed Opportunity to Deprescribe”
- July 2015 “Tools
for Deprescribing”
- November 2015 “Medications
Most Likely to Harm the Elderly Are…”
- August 2, 2016 “Drugs
in the Elderly: The Goldilocks Story”
Some of our past columns on deprescribing:
- March 4, 2014 “Evidence-Based
Prescribing and Deprescribing in the Elderly”
- September 30, 2014 “More
on Deprescribing”
- May 2015 “Hospitalization:
Missed Opportunity to Deprescribe”
- July 2015 “Tools
for Deprescribing”
- April 4, 2017 “Deprescribing
in Long-Term Care”
References:
Wouters H, Scheper
J, Koning H, et al.
Discontinuing Inappropriate Medication Use in Nursing Home Residents: A Cluster
Randomized Controlled Trial. Ann Intern Med 2017; published online October 10,
2017
Renom-Guiteras A, Thürmann PA, Miralles TR, et al.Potentially inappropriate
medication among people with dementia in eight European countries. Age and
Ageing 2017; Published online 01 September 2017
Paauw DS. 11 Drugs You Should
Seriously Consider Deprescribing. Medscape 2017;
September 5, 2017
http://www.medscape.com/slideshow/deprescribing-6009041?src=wnl_edit_tpal&uac=14695HV
Merel SE, Paauw
DS. Common Drug Side Effects and Drug-Drug Interactions in Elderly Adults in
Primary Care. J Am Geriatr Soc 2017;
65(7): 1578-1585
http://onlinelibrary.wiley.com/doi/10.1111/jgs.14870/full
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