Provider Insider

Are our patients overmedicated? A toolkit addressing polypharmacy and deprescribing.

 

Polypharmacy, defined as taking five or more medications, was estimated to be 36% in 2011 and will likely increase in the coming years.¹ Oftentimes, patients are started on medications that are never adjusted or stopped, leading to clinical inertia and poor outcomes of drug-related events, hospitalizations, etc. One way to prevent these outcomes is through deprescribing unnecessary medications. Deprescribing is defined as the planned and supervised process of dose reduction or stopping of medication(s) that may be causing harm or are no longer beneficial.² This article will provide supportive literature for deprescribing, as well as helpful tools for doing so.

 

Why is this important?

 

Deprescribing has the potential to impact all aspects of the Quadruple Aim: improved population health, reduced costs (to patients and the health system), enhanced patient experience/satisfaction, and improved work life for providers. Improving the quality of health care, while decreasing costs is quintessential to the success of our health care system.

 

What is the Population Health team doing to address this?

 

Our clinical pharmacy team is currently performing prospective comprehensive medication reviews (CMRs) for patients with upcoming appointments with the intent of optimizing chronic condition management and ensuring accurate medication lists. Part of this process is recommending the deprescribing of select medications to prevent polypharmacy, improve adherence and decrease poor outcomes. Below is a list of medications that are recommended to be deprescribed, if appropriate.

 

Common medications to consider deprescribing:

 

Medication	Deprescribing Recommendation	Rationale
NSAIDs (e.g., ibuprofen, naproxen, celecoxib, etc.)	Recommend deprescribing in patients with congestive heart failure, gastric/duodenal ulcers or CKD.	NSAIDs are associated with worsening fluid retention, precipitation of ulcers, declined renal function, and risk of myocardial infarction.
Anticholinergics (antidepressants, antihistamines, antimuscarinics, muscle relaxants)	Recommend deprescribing, if appropriate, especially in older individuals or those with BPH.	Anticholinergics place patients at increased risk of falls, xerostomia, urinary retention, constipation, etc.
Non-statin medications (e.g., ezetimibe, colesevelam, colestipol, cholestyramine, etc.)	Recommend deprescribing in patients using as monotherapy for cardiovascular risk reduction. Instead, assess indication for statin therapy in these patients.	2018 ACC/AHA cholesterol guidelines do not recommend use of these agents as monotherapy for cardiovascular risk reduction.
Proton pump inhibitors (e.g., omeprazole, esomeprazole, pantoprazole, lansoprazole, etc.)	Guidelines recommend deprescribing PPI therapy in patients who have completed 4 weeks of PPI treatment for heartburn. This recommendation does not apply to patients using PPIs for esophagitis or GI ulcers.3	PPIs are associated with C. difficile infections, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, chronic kidney disease and dementia.
Benzodiazepines (e.g., alprazolam, clonazepam, diazepam, lorazepam, oxazepam, etc.)	Recommend deprescribing (via tapering) benzodiazepines in patients ≥65 years of age or 18-64 years of age who have used benzodiazepines for ≥4 weeks.4	Benzodiazepines are associated with dependency, falls, fractures and cognitive decline in older individuals.
Antipsychotics (e.g., haloperidol, loxapine, aripiprazole, clozapine, olanzapine, paliperidone, quetiapine, risperidone, etc.)	Recommend deprescribing antipsychotics in patients who have had symptoms of dementia for ≥3 months.5	Antipsychotics are associated with drowsiness, headache, extrapyramidal symptoms, weight gain and death in patients with dementia.
Antihyperglycemics (specifically ones that cause hypoglycemia—insulin, sulfonylureas, meglitinides)	Recommend deprescribing antihyperglycemic medications known to contribute to hypoglycemia and individualize targets for patients who are frail, have dementia, or have a limited life expectancy.6	Certain classes of antihyperglycemics (insulin, sulfonylureas, etc.) are associated with hypoglycemia and potentially subsequent falls and/or hospitalizations.
Cholinesterase inhibitors (e.g., donepezil, galantamine, rivastigmine, memantine, etc.)	Recommend discontinuing if cognition/function has significantly declined, no benefit has been noticed since beginning treatment, or if individual has severe/end-stage dementia.7	If patient not receiving benefit, or cognitive function is declining while taking, it is likely the cholinesterase inhibitor is not working. Thus, in attempt to decrease pill burden, adverse effects from the drug and cost, deprescribing can be considered.

 

Key messages:

• Deprescribing unnecessary medications can prevent adverse outcomes and should be considered when able.
• There are many resources to help assess and guide deprescribing (see appendices below).
• Deprescribing may have additional benefit of cost savings to both the patient and health system.
• Population health clinical pharmacists are currently performing comprehensive medication reviews on high-risk patients to help guide deprescribing practices.

Questions or comments? Please contact [email protected].

 

Kyle Troksa, Pharm.D., PGY2 Ambulatory Care resident, authored this article.

 

 

References

1. Qato DM, Wilder J, Schumm LP, et al. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016;176(4):473-82.
2. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-34.
3. Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, Rojas-Fernandez C, Walsh K, Welch V, Moayyedi P. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017 May;63(5):354-364.
4. Pottie K, Thompson W, Davies S, Grenier J, Sadowski CA, Welch V, Holbrook A, Boyd C, Swenson R, Ma A, Farrell B. Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Can Fam Physician. 2018 May;64(5):339-351.
5. Bjerre LM, Farrell B, Hogel M, Graham L, Lemay G, McCarthy L, Raman-Wilms L, Rojas-Fernandez C, Sinha S, Thompson W, Welch V, Wiens A. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: Evidence-based clinical practice guideline. Can Fam Physician. 2018 Jan;64(1):17-27.
6. Farrell B, Black C, Thompson W, McCarthy L, Rojas-Fernandez C, Lochnan H, Shamji S, Upshur R, Bouchard M, Welch V. Deprescribing antihyperglycemic agents in older persons: Evidence-based clinical practice guideline. Can Fam Physician. 2017 Nov;63(11):832-843.
7. Reeve E, Farrell B, Thompson W, Herrmann N, Sketris I, Magin P, Chenoweth L, Gorman M, Quirke L, Bethune G, Forbes F, Hilmer S. Evidence-based Clinical Practice Guideline for Deprescribing Cholinesterase Inhibitors and Memantine: Recommendations. Sydney: The University of Sydney; 2018.

 

Appendix

 

Deprescribing resources (click link to access resource):

• Beers Criteria—list of potentially inappropriate medications in the elderly.
• Deprescribing.org—provides deprescribing guidelines and education.
• Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE)—assessment for medication-related deficiencies in older adults.
• Medi-Cog—combination of a Mini-Cog and medication transfer screen, assessing patient’s ability to properly fill a pillbox.
• Good Palliative-Geriatric Practice Algorithm—algorithm for stopping or changing pharmacologic therapy in the palliative care population.

 

Stepwise approach to deprescribing:

1. Review patient’s medications (in person if possible).
2. Discuss the goal and expectations of deprescribing with patient.
3. Deprescribe medications that:
   • Are potentially inappropriate.
   • Lack therapeutic efficacy.
   • Lack a clear indication.
   • Are unlikely to provide benefit in the patient’s lifetime.
   • The patient would like to stop (i.e., adverse side effect).
   • Have complex dosing regimens.
4. Create follow-up plan.