It was only earlier this year that we first saw the term “deprescribing” (see our March 4, 2014 Patient Safety Tip of the Week “Evidence-Based Prescribing and Deprescribing in the Elderly”). But we’ve obviously long been big advocates of discontinuing medications which no longer have a positive benefit:harm ratio (see the list of all our previous columns on inappropriate medications at the end of today’s column).
This month the Medical Journal of Australia has several good articles on deprescribing. The first article (Scott 2014) chronicles the statistics on the consequences of polypharmacy and then describes the barriers to deprescribing.
The first barrier to deprescribing noted by Scott and colleagues is an underappreciation of the magnitude of polypharmacy-related harm. They note that many times symptoms in the elderly (such as falls, delirium, lethargy, depression) are not recognized as adverse drug events.
A second barrier is the increasing intensity of medical care. Prescription of many medications is driven by clinical guidelines, quality measures, and performance incentives. They note that this often results in “prescribing cascades” in which more drugs are added for new illness, including some that are actually adverse drug events (ADE’s) misinterpreted as new illnesses.
A very important point raised by Scott et al. is the drugs on which we focus may be wrong. Many of the potentially inappropriate medications on Beers’ List actually probably account for relatively few adverse drug events in aggregate. In our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?” we noted that the STOPP criteria identified potentially avoidable ADE’s impacting on hospitalization over twice as often as did Beers’ criteria and that such ADE’s are extremely common. Scott et al. point out the work of Budnitz and colleagues (Budnitz 2011) that showed most emergency hospitalizations for recognized adverse drug events in older adults resulted from a few commonly used medications (eg. warfarin, antiplatelet agents, insulins, oral hypoglycemic agents) and relatively few resulted from medications typically designated as high-risk or inappropriate in such lists.
One of the barriers to deprescribing noted by Scott and colleagues is a reluctance by physicians to discontinue a medication started by another physician, especially those started by a specialist. We agree that such is a barrier. But one equally big barrier we see is reluctance to discontinue medications that they themselves started. We’ve previously described an initiative in a health system in which physicians were made aware of the potential adverse effects of amitriptyline in the elderly. The number of new prescriptions for amitriptyline decreased but almost never did the physicians discontinue amitriptyline they had already prescribed for their patients.
The patient’s fear or ambivalence is another barrier. Patients are often reluctant to stop a drug that had improved symptoms in the past or had been expected to prolong life or have other long-term benefits. They may perceive deprescribing as “abandonment” rather than as an attempt to improve their quality of life or decrease risks of adverse events.
Scott and colleagues mention, but don’t emphasize, what we consider to be a huge barrier: limited time and remuneration for deprescribing. It is very time consuming to sit down and go over all the medications, go back in history to find out why and by whom certain medications were prescribed, discuss the pros and cons of medication cessation with the patient, communicate with other physicians about discontinuation, and then monitor the patient for unwanted effects once a medication is discontinued. Most of that time is not reimbursed in our current payment systems. (But that is where exists an opportunity to fully utilize other members of the healthcare team to do some of the legwork.)
Scott et al. offer several potential solutions. One important one is reframing the issue, to make sure the patient understands deprescribing is an attempt to improve their quality of life or decrease risks of adverse events and not an act of abandonment. That’s extremely important in maintaining trust and preserving the physician-patient relationship. We need to discuss the benefit:harm tradeoffs for discontinuation of each drug and assess the patient’s willingness to try discontinuation. They suggest targeting those patients at highest risk for ADE’s. That includes not only patients on the most drugs but also those with past history of ADE’s, frailty, multiple comorbidities, multiple prescribers, and those in residential settings.
They suggest targeting drugs most likely to be non-beneficial, which they consider in 5 categories:
Giving the physician access to specific discontinuation regimens is important and Scott et al. provide links to websites and other resources in their article. Lastly, Scott et al. recommend interdisciplinary meetings with other prescribers and clinical pharmacologists or pharmacists, and stress the importance of having the same generalist clinician overseeing the process over multiple visits.
We had actually previously mentioned Dr. Scott’s approach to deprescribing (see our March 4, 2014 Patient Safety Tip of the Week “Evidence-Based Prescribing and Deprescribing in the Elderly”). Scott and colleagues (Scott 2012) had developed a 10 step conceptual framework for minimizing inappropriate medications in older populations and deprescribing:
The second MJA article (Reeve 2014), also supportive of deprescribing in general, is a bit more cautious and points out that there is actually a dearth of evidence on actual patient outcome benefits of deprescribing. Reeve and colleagues note that of the multiple studies demonstrating interventions that successfully reduce polypharmacy only half included outcome measures other than number of drugs and only one-third of the latter showed a benefit in clinical outcomes. Similarly, the effect of programs to reduce potentially inappropriate medications on clinical outcomes has not been rigorously studied.
Reeve et al. discuss several potential harms of deprescribing. One is the occurrence of withdrawal reactions. They cite previous studies that showed 26% of medication cessations in older adults resulted in adverse withdrawal reactions, sometimes resulting in ER visits or even hospitalizations. However, they note that appropriate tapering of medications prior to cessation can prevent many such reactions.
They also note that drug interactions may affect medications other than the one being discontinued. Our May 27, 2014 Patient Safety Tip of the Week “A Gap in ePrescribing: Stopping Medications” described one such example. So it is imperative that patients be monitored after medication cessation just as we would monitor patients at the start of a new medication.
Return of the medical condition for which the drug was originally prescribed is a concern for both patients and physicians. But, generally, restarting the medication in such instances is usually successful. They note particularly that the impact of cessation of preventive medications, where the benefit is many years from now, has not been well studied.
There are several good resources available that have algorithms or frameworks for discontinuing medications (Scott 2013, Bain 2008, Garfinkel 2010). The 2013 Scott (Scott 2013) and 2010 Bain (Bain 2008) articles have examples of drugs that are commonly associated with discontinuation or withdrawal symptoms and signs. The 2013 article by Scott et al. (Scott 2013) also has a table with good questions to ask about the utility of a drug.
But there is one area in which the greatest opportunity exists to help in medication cessation – when you first prescribe a drug! When you prescribe a medication for a patient you should have an exit strategy. You should be asking yourself (and discussing with your patient) the following questions:
In many ways, stopping a medication is much more complex than starting one. Deprescribing, particularly in the elderly, can be a very important process in improving patient quality of life, reducing risk of adverse consequences, and reducing morbidity. Once drugs with poor benefit:risk ratios are discontinued, patients may also become more adherent to other medications which may have high benefit:risk ratios.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Patient Safety Tips of the Week:
What’s New in the Patient Safety World columns:
Scott IA, Anderson K, Freeman CR, Stowasser DA. First do no harm: a real need to deprescribe in older patients. Med J Aust 2014; 201(7): 1-3
Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011; 365: 2002-2012
Scott IA, Gray LC, Martin JH, Mitchell CA. Minimizing inappropriate medications in older populations: a 10 step conceptual framework. Am J Med 2012; 125: 529–537
Reeve E, Shakib S, Hendrix I, et al. The benefits and harms of deprescribing. Med J Aust 2014; 201(7): 1-4
Scott IA, Gray LC, Martin JH, et al. Deciding when to stop: towards evidence based deprescribing of drugs in older populations. Evid Based Med 2013; 18: 121–124
Bain KT, Holmes HM, Beers MH, et al. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc 2008; 56(10): 1946–1952
Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Arch Intern Med 2010; 170(18): 1648–1654
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